hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Richard Medical Center,2024-03-08,2.0.0,Richard Medical Center,"254 Highway 3048 Bayville, LA 71269",721179028,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|AMERIHEALTH|COMMERCIAL|negotiated_dollar,standard_charge|AMERIHEALTH|COMMERCIAL|negotiated_percentage,standard_charge|AMERIHEALTH|COMMERCIAL|negotiated_algorithm,estimated_amount|AMERIHEALTH|COMMERCIAL,standard_charge|AMERIHEALTH|COMMERCIAL|methodology,additional_payer_notes|AMERIHEALTH|COMMERCIAL,standard_charge|BCBS|HMO|negotiated_dollar,standard_charge|BCBS|HMO|negotiated_percentage,standard_charge|BCBS|HMO|negotiated_algorithm,estimated_amount|BCBS|HMO,standard_charge|BCBS|HMO|methodology,additional_payer_notes|BCBS|HMO,standard_charge|BCBS|PPO|negotiated_dollar,standard_charge|BCBS|PPO|negotiated_percentage,standard_charge|BCBS|PPO|negotiated_algorithm,estimated_amount|BCBS|PPO,standard_charge|BCBS|PPO|methodology,additional_payer_notes|BCBS|PPO,standard_charge|BCBS|TRADITIONAL|negotiated_dollar,standard_charge|BCBS|TRADITIONAL|negotiated_percentage,standard_charge|BCBS|TRADITIONAL|negotiated_algorithm,estimated_amount|BCBS|TRADITIONAL,standard_charge|BCBS|TRADITIONAL|methodology,additional_payer_notes|BCBS|TRADITIONAL,standard_charge|BCBS|MEDICARE|negotiated_dollar,standard_charge|BCBS|MEDICARE|negotiated_percentage,standard_charge|BCBS|MEDICARE|negotiated_algorithm,estimated_amount|BCBS|MEDICARE,standard_charge|BCBS|MEDICARE|methodology,additional_payer_notes|BCBS|MEDICARE,standard_charge|CIGNA|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|methodology,additional_payer_notes|CIGNA|COMMERCIAL,standard_charge|COVENTRY|HMO|negotiated_dollar,standard_charge|COVENTRY|HMO|negotiated_percentage,standard_charge|COVENTRY|HMO|negotiated_algorithm,estimated_amount|COVENTRY|HMO,standard_charge|COVENTRY|HMO|methodology,additional_payer_notes|COVENTRY|HMO,standard_charge|COVENTRY|POS|negotiated_dollar,standard_charge|COVENTRY|POS|negotiated_percentage,standard_charge|COVENTRY|POS|negotiated_algorithm,estimated_amount|COVENTRY|POS,standard_charge|COVENTRY|POS|methodology,additional_payer_notes|COVENTRY|POS,standard_charge|COVENTRY|PPO|negotiated_dollar,standard_charge|COVENTRY|PPO|negotiated_percentage,standard_charge|COVENTRY|PPO|negotiated_algorithm,estimated_amount|COVENTRY|PPO,standard_charge|COVENTRY|PPO|methodology,additional_payer_notes|COVENTRY|PPO,standard_charge|COVENTRY|ASO|negotiated_dollar,standard_charge|COVENTRY|ASO|negotiated_percentage,standard_charge|COVENTRY|ASO|negotiated_algorithm,estimated_amount|COVENTRY|ASO,standard_charge|COVENTRY|ASO|methodology,additional_payer_notes|COVENTRY|ASO,standard_charge|COVENTRY|OPM|negotiated_dollar,standard_charge|COVENTRY|OPM|negotiated_percentage,standard_charge|COVENTRY|OPM|negotiated_algorithm,estimated_amount|COVENTRY|OPM,standard_charge|COVENTRY|OPM|methodology,additional_payer_notes|COVENTRY|OPM,standard_charge|COVENTRY|NETWORK_ACCESS|negotiated_dollar,standard_charge|COVENTRY|NETWORK_ACCESS|negotiated_percentage,standard_charge|COVENTRY|NETWORK_ACCESS|negotiated_algorithm,estimated_amount|COVENTRY|NETWORK_ACCESS,standard_charge|COVENTRY|NETWORK_ACCESS|methodology,additional_payer_notes|COVENTRY|NETWORK_ACCESS,standard_charge|GILSBAR|PPO|negotiated_dollar,standard_charge|GILSBAR|PPO|negotiated_percentage,standard_charge|GILSBAR|PPO|negotiated_algorithm,estimated_amount|GILSBAR|PPO,standard_charge|GILSBAR|PPO|methodology,additional_payer_notes|GILSBAR|PPO,standard_charge|HUMANA|EPO|negotiated_dollar,standard_charge|HUMANA|EPO|negotiated_percentage,standard_charge|HUMANA|EPO|negotiated_algorithm,estimated_amount|HUMANA|EPO,standard_charge|HUMANA|EPO|methodology,additional_payer_notes|HUMANA|EPO,standard_charge|HUMANA|HMO|negotiated_dollar,standard_charge|HUMANA|HMO|negotiated_percentage,standard_charge|HUMANA|HMO|negotiated_algorithm,estimated_amount|HUMANA|HMO,standard_charge|HUMANA|HMO|methodology,additional_payer_notes|HUMANA|HMO,standard_charge|HUMANA|POS|negotiated_dollar,standard_charge|HUMANA|POS|negotiated_percentage,standard_charge|HUMANA|POS|negotiated_algorithm,estimated_amount|HUMANA|POS,standard_charge|HUMANA|POS|methodology,additional_payer_notes|HUMANA|POS,standard_charge|HUMANA|PPO|negotiated_dollar,standard_charge|HUMANA|PPO|negotiated_percentage,standard_charge|HUMANA|PPO|negotiated_algorithm,estimated_amount|HUMANA|PPO,standard_charge|HUMANA|PPO|methodology,additional_payer_notes|HUMANA|PPO,standard_charge|HUMANA|MEDICARE_HMO|negotiated_dollar,standard_charge|HUMANA|MEDICARE_HMO|negotiated_percentage,standard_charge|HUMANA|MEDICARE_HMO|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_HMO,standard_charge|HUMANA|MEDICARE_HMO|methodology,additional_payer_notes|HUMANA|MEDICARE_HMO,standard_charge|HUMANA|MEDICARE_POS|negotiated_dollar,standard_charge|HUMANA|MEDICARE_POS|negotiated_percentage,standard_charge|HUMANA|MEDICARE_POS|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_POS,standard_charge|HUMANA|MEDICARE_POS|methodology,additional_payer_notes|HUMANA|MEDICARE_POS,standard_charge|HUMANA|MEDICARE_PPO|negotiated_dollar,standard_charge|HUMANA|MEDICARE_PPO|negotiated_percentage,standard_charge|HUMANA|MEDICARE_PPO|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_PPO,standard_charge|HUMANA|MEDICARE_PPO|methodology,additional_payer_notes|HUMANA|MEDICARE_PPO,standard_charge|LA_HEALTHCARE_CONNECTIONS|COMMERCIAL|negotiated_dollar,standard_charge|LA_HEALTHCARE_CONNECTIONS|COMMERCIAL|negotiated_percentage,standard_charge|LA_HEALTHCARE_CONNECTIONS|COMMERCIAL|negotiated_algorithm,estimated_amount|LA_HEALTHCARE_CONNECTIONS|COMMERCIAL,standard_charge|LA_HEALTHCARE_CONNECTIONS|COMMERCIAL|methodology,additional_payer_notes|LA_HEALTHCARE_CONNECTIONS|COMMERCIAL,standard_charge|MEDICAID|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|MEDICAID,standard_charge|MEDICAID|MEDICAID|methodology,additional_payer_notes|MEDICAID|MEDICAID,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_dollar,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_percentage,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_algorithm,estimated_amount|MULTIPLAN|COMMERCIAL,standard_charge|MULTIPLAN|COMMERCIAL|methodology,additional_payer_notes|MULTIPLAN|COMMERCIAL,standard_charge|PEOPLES_HEALTH_NETWORK|COMMERCIAL|negotiated_dollar,standard_charge|PEOPLES_HEALTH_NETWORK|COMMERCIAL|negotiated_percentage,standard_charge|PEOPLES_HEALTH_NETWORK|COMMERCIAL|negotiated_algorithm,estimated_amount|PEOPLES_HEALTH_NETWORK|COMMERCIAL,standard_charge|PEOPLES_HEALTH_NETWORK|COMMERCIAL|methodology,additional_payer_notes|PEOPLES_HEALTH_NETWORK|COMMERCIAL,standard_charge|PPO_PLUS|COMMERCIAL|negotiated_dollar,standard_charge|PPO_PLUS|COMMERCIAL|negotiated_percentage,standard_charge|PPO_PLUS|COMMERCIAL|negotiated_algorithm,estimated_amount|PPO_PLUS|COMMERCIAL,standard_charge|PPO_PLUS|COMMERCIAL|methodology,additional_payer_notes|PPO_PLUS|COMMERCIAL,standard_charge|PPO_PLUS_EMPLOYEES|COMMERCIAL|negotiated_dollar,standard_charge|PPO_PLUS_EMPLOYEES|COMMERCIAL|negotiated_percentage,standard_charge|PPO_PLUS_EMPLOYEES|COMMERCIAL|negotiated_algorithm,estimated_amount|PPO_PLUS_EMPLOYEES|COMMERCIAL,standard_charge|PPO_PLUS_EMPLOYEES|COMMERCIAL|methodology,additional_payer_notes|PPO_PLUS_EMPLOYEES|COMMERCIAL,standard_charge|UHC|COMMERCIAL|negotiated_dollar,standard_charge|UHC|COMMERCIAL|negotiated_percentage,standard_charge|UHC|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC|COMMERCIAL,standard_charge|UHC|COMMERCIAL|methodology,additional_payer_notes|UHC|COMMERCIAL,standard_charge|UHC|MEDICAID|negotiated_dollar,standard_charge|UHC|MEDICAID|negotiated_percentage,standard_charge|UHC|MEDICAID|negotiated_algorithm,estimated_amount|UHC|MEDICAID,standard_charge|UHC|MEDICAID|methodology,additional_payer_notes|UHC|MEDICAID,standard_charge|VANTAGE|COMMERCIAL|negotiated_dollar,standard_charge|VANTAGE|COMMERCIAL|negotiated_percentage,standard_charge|VANTAGE|COMMERCIAL|negotiated_algorithm,estimated_amount|VANTAGE|COMMERCIAL,standard_charge|VANTAGE|COMMERCIAL|methodology,additional_payer_notes|VANTAGE|COMMERCIAL,standard_charge|VANTAGE|MEDICARE|negotiated_dollar,standard_charge|VANTAGE|MEDICARE|negotiated_percentage,standard_charge|VANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|VANTAGE|MEDICARE,standard_charge|VANTAGE|MEDICARE|methodology,additional_payer_notes|VANTAGE|MEDICARE,standard_charge|VANTAGE|METAL|negotiated_dollar,standard_charge|VANTAGE|METAL|negotiated_percentage,standard_charge|VANTAGE|METAL|negotiated_algorithm,estimated_amount|VANTAGE|METAL,standard_charge|VANTAGE|METAL|methodology,additional_payer_notes|VANTAGE|METAL,standard_charge|VERITY|COMMERCIAL|negotiated_dollar,standard_charge|VERITY|COMMERCIAL|negotiated_percentage,standard_charge|VERITY|COMMERCIAL|negotiated_algorithm,estimated_amount|VERITY|COMMERCIAL,standard_charge|VERITY|COMMERCIAL|methodology,additional_payer_notes|VERITY|COMMERCIAL,standard_charge|min,standard_charge|max,additional_generic_notes
VAXNEUVANCE 0.5 ML,61,CDM,636,RC,,,both,,,430.62,322.97,,344.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.28,430.62,
CRYOSURGERY 1.1 TO 2.0,17262,CDM,521,RC,17262,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,309.77,
DECADRON 4 MG TAB,3200209,CDM,637,RC,J8540,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DELTASONE 10MG,3200216,CDM,637,RC,J7512,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
INS CREDIT ADJ.,99211,CDM,214,RC,,,inpatient,,,,,,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1853,100,,,per diem,100% Multiplan step down per diem rate.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,2737.25,
ADAPTER BRONCHOSCOPE 11547,100003,CDM,272,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
SENSOR ADHESIVE LNCS NEONATAL,100010,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NASAL CANNULA CO2 SAMPLING ADULT,100013,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
AIRWAY NASAL 28FR (6.5MM),100014,CDM,270,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BERMAN AIRWAY 90MM,100015,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
ALCOHOL PT-10102,100018,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
SAFE-T-CENTESIS TRAY - DR PROCTOR,100019,CDM,270,RC,,,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.81,136.8,
AMBU BAG N10258,100023,CDM,270,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
QUICK TRACH II WITH CUFF,100025,CDM,270,RC,,,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
QUICK TRACH 2.0 MM EMERGENCY KIT,100026,CDM,270,RC,,,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,320,
QUICK TRACH 4.0 MM EMERGENCY KIT,100027,CDM,270,RC,,,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,320,
AQUA KPAD N11174,100028,CDM,270,RC,,,outpatient,,,13.65,10.24,,10.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.49,10.92,
PERICARDIOCENTESIS KIT,100029,CDM,270,RC,,,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,320,
DO NOT ORDER KING VISION CHANNEL DISP,100032,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
KY JELLY TUBE 4 OZ,100033,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
DO NOT USE KY JELLY PACKET 5 GRAM,100034,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
ARTERIAL LINE KIT,100035,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
SKIN AFFIX (AKA DERMA-FLEX) EXOFIN,100041,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NEEDLES 22 GA X 1 1/2,100042,CDM,270,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
BAG BILE,100045,CDM,271,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BAG DRAINAGE 2000 ML #6206,100046,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
MULTI-LUMEN CVC KIT ASK-45703-AKP1A,100047,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
SOCKS NON SKID,100048,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
DON'T ORDER AIRWAY NASOPHARYNGEAL 6.5MM,100049,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
BAG LEG 10648,100050,CDM,271,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
CATHETER RADIAL ARTERY SET,100051,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
BOOT UNNA (GELOCAST) 4,100052,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
BANDAGE ACE 2,100055,CDM,271,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
BANDAGE ACE 3,100056,CDM,271,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
BANDAGE ACE 4,100057,CDM,271,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
BANDAGE ACE 6,100058,CDM,271,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
TOURNIQUET LATEX FREE,100060,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
BANDAGE STERILE FINGER COT,100061,CDM,272,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BASIC PACK,100066,CDM,272,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
TOWEL OR STERILE 4 PK,100068,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
ZOLL ADULT CPR ELECTRODES,100070,CDM,270,RC,,,outpatient,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.54,180,
ZOLL PED/ADULT AIRWAY ADAPTER,100071,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
ZOLL PEDIATRIC CPR ELECTRODE,100073,CDM,270,RC,,,outpatient,,,136.5,102.38,,109.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.93,109.2,
ELECTRODE RED DOT ADULT,100081,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
WAFER STOMAHESIVE 1 3/4 NATURA,100082,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
POUCH OSTOMY CLOSED 2 1/4,100083,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
POUCH OSTOMY CLOSED 2 3/4,100084,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DONT USE LANCET W/NEEDLE PUSH BUTTON,100086,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DRESSING CHANGE KIT,100087,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
GRADUATED CONTAINER,100091,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
BLADES SURG ALL STANDARD 371110,100092,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SCALPEL DISPOSABLE #10,100093,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
RULER PAD WOUND MEASURING,100094,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BLOOD / FLUID WARMING SET,100095,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
GUIDE WOUND MEASURING PLASTIC CIRCLE,100096,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DO NOT ORDER BOTTLE EMERSON (550-3060),100101,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
PENCIL ELECTROSURG ROCKER BOVIE,100102,CDM,271,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
BREATHING CIRCUIT  10302,100105,CDM,272,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
DRESSING DUO DERM 4 X4 EXTRA THIN,100106,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BREATHING CIRCUIT PED 10303,100107,CDM,272,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
SHOULDER IMMOBILIZER XXL,100108,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
SHOULDER IMMOBILIZER XL,100109,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
CAP CUROS DISINFECTING,100110,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BRUSH PEG FEEDING TUBE 10784,100111,CDM,270,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
BRUSH SCRUB,100112,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CLOSED WOUND SUCTION KIT 1/8,100113,CDM,270,RC,,,outpatient,,,16.2,12.15,,12.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.52,12.96,
C02 MONITOR,100115,CDM,270,RC,,,outpatient,,,111.5,83.63,,89.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.87,89.2,
ADHESIVE REMOVER SPRAY SENSI-CARE,100116,CDM,270,RC,,,outpatient,,,19.16,14.37,,15.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.71,15.33,
DO NOT ORDER CANNULA CLIP LOCK 11378,100117,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
KIT HIP KNEE REPLACEMENT W/LEG LIFTER/GR,100118,CDM,270,RC,,,outpatient,,,79.94,59.96,,63.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.17,63.95,
BELT FEMALE UNIVERSAL RIB,100119,CDM,270,RC,,,outpatient,,,8.06,6.05,,6.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.24,6.45,
BELT MALE UNIVERSAL RIB,100120,CDM,270,RC,,,outpatient,,,8.06,6.05,,6.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.24,6.45,
KING VISION #3 NON-CHANNELED BLADE,100121,CDM,270,RC,,,outpatient,,,55.8,41.85,,44.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.45,44.64,
ELECTRODE STIMULATOR FABSTIM 2  SQUARE,100122,CDM,270,RC,,,outpatient,,,1.15,0.86,,0.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.46,0.92,
SLEEVES SMALL MEDLINE DVT,100123,CDM,270,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
SLEEVES MEDIUM MEDLINE DVT,100124,CDM,270,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
DONT USE CATH ALL PURPOSE,100125,CDM,272,RC,,,outpatient,,,11.5,8.63,,9.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.63,9.2,
SLEEVES XL MEDLINE DVT,100126,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SLEEVES LARGE MEDLINE DVT,100127,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
ARMBOARD INFANT 1 X 4,100128,CDM,270,RC,,,outpatient,,,0.41,0.31,,0.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.33,
CUFF DISP BP LG ADULT,100131,CDM,270,RC,,,outpatient,,,4.92,3.69,,3.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.98,3.94,
CATH COUDE 12 FR (BULB),100132,CDM,272,RC,,,outpatient,,,65.5,49.13,,52.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.36,52.4,
CATH COUDE FOLEY RADIOPAQUE 11456,100133,CDM,272,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
CUFF DISP BP ADULT,100134,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CATH COUDE TIP 10397 10116,100135,CDM,272,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
CONNECTOR MALE FLEXPORT (BAYONET),100136,CDM,270,RC,,,outpatient,,,0.95,0.71,,0.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.38,0.76,
CATH FEMALE KIT DYND10805-10682,100140,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
CATH FLATUS BAG 24FR,100141,CDM,270,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
CATH FOLEY 10FR 2WAY-11449,100142,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
DO NOT ORDER CATH FOLEY 26FR 2WAY,100143,CDM,272,RC,,,outpatient,,,10.25,7.69,,8.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.12,8.2,
DO NOT ORDER CATH FOLEY COUDE 10411-19,100144,CDM,272,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
CATHETER FOLEY 16 5CC,100147,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
SOAP DISH GRAPHITE,100148,CDM,270,RC,,,outpatient,,,0.15,0.11,,0.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.12,
ACCU-CHEK LANCET SAFE-T PRO PLUS,100150,CDM,270,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
ACCU-CHECK STRIP GLUCOSE MONITOR,100151,CDM,270,RC,,,outpatient,,,0.69,0.52,,0.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.28,0.55,
CUP DRINKING W/STRAW FOR ADMIT KIT,100152,CDM,270,RC,,,outpatient,,,3.7,2.78,,2.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.49,2.96,
DRAWSTRING BAG,100153,CDM,270,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
CATH STRAP LEG,100160,CDM,270,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
CATH STRAP MALE/TEXAS,100161,CDM,271,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
THORACIC CATH STRAIGHT 28FR,100167,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
CATH TRAY OPEN URET,100169,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
CATH URETHAL 10FR  ALL PURPOSE,100170,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CHEST DRAINAGE PLEUR PVAC 11028,100176,CDM,272,RC,,,outpatient,,,525,393.75,,420,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,211.26,420,
COFLEX NON STERILE,100185,CDM,271,RC,,,outpatient,,,2.4,1.8,,1.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.92,
ICE PACKS LARGE,100186,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
CONNECTOR 5 IN 1 BUBBLE CONNECTOR,100188,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
CONNECTOR Y-PORT 11304,100189,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
CYSTOSCOPY PACK (OR) CY015-10638,100199,CDM,272,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
DO NOT ORDER DEFIBRILLATION PADS 11298,100200,CDM,270,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
HEEL/ELBOW PROTECTOR (UNIV),100237,CDM,271,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
STOCKING THIGH HI X-LG,100280,CDM,271,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DRAIN BLAKE 10FR RND,100291,CDM,272,RC,,,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,70.4,
DRAIN PENROSE 1/4 X18,100294,CDM,271,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
DRAIN SURGIVAC 11303,100296,CDM,272,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
DO NOT ORDER DRAINAGE TUBE 10632,100299,CDM,272,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
DRESSING ADAPTIC 3X8 JJ2013-10666 KEND61,100310,CDM,272,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
DRESSING ADAPTIC JJ2012-10667 JJ2012B,100311,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
DRESSING ISLAND 4X5,100315,CDM,272,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DRESSING ISLAND  6 X 7,100316,CDM,272,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DRESSING XEROFORM 10665,100320,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
EGGCRATE LG ICU 11112,100325,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
ELECTRODE ECG INFANT 11322 2283,100328,CDM,271,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
ELECTRODE ECG SILVON 11297,100329,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
ELECTRODES - PT RETURN 10375,100334,CDM,270,RC,,,outpatient,,,9.6,7.2,,7.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.86,7.68,
ELECTRODES BLUE MAX,100335,CDM,270,RC,,,outpatient,,,8.71,6.53,,6.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.5,6.97,
DO NOT ORDER ELECTROSURGICAL PENCIL,100336,CDM,272,RC,,,outpatient,,,164,123,,131.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.99,131.2,
ENDOCLOSE / SUTURE PASSER,100348,CDM,270,RC,,,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,182.4,
ENDOSCOPIC KITTNER EN9101,100351,CDM,270,RC,,,outpatient,,,51.5,38.63,,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.72,41.2,
DONT USE ENDOSCOPY PACK 10900,100353,CDM,272,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
ESOPHAGEAL STETHOSCOPE,100360,CDM,270,RC,,,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,11.6,
EYE PAD OVAL,100361,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
FACE MASK PED SZ 4 (1145),100366,CDM,270,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
DNU FOLEY TRAY W/O CATH DYND11020-10764,100376,CDM,272,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
GAUZE IDOFORM PACKING 1 X 5,100377,CDM,272,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
GAUZE IDOFORM PACKING 2 X 5,100378,CDM,272,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
GAUZE SPONGES 2X2 NONSTERILE 10145,100381,CDM,270,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
GAUZE VASOLINE 3X18,100382,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
GAUZE VASOLINE 3X9,100383,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
GLASSES PROTECTIVE,100388,CDM,270,RC,,,outpatient,,,6.75,5.06,,5.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.72,5.4,
GOWN LARGE,100394,CDM,272,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
GOWN XL,100397,CDM,272,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DO NOT ORDER HEAD HALTER 11530,100402,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
INFUSION PRESSURE BAG,100415,CDM,270,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
INTUBATING STYLET 6FR,100418,CDM,272,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
GAUZE PLAIN PACKING 1/4 X 5,100419,CDM,272,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
IRRIGATION SET CYSTO/BLADR,100422,CDM,272,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
IRRIGATION SET CYSTO Y TYPE 11301,100423,CDM,272,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
IRRIGATION TRAY,100424,CDM,270,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
IV CATH 20G X 1 11650,100428,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
IV-CATH 16G X 1-3/4  GREY,100429,CDM,272,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DO NOT ORDERIV EXTENSION SET CLAVE 11399,100432,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NO NOT USE IV SET ADMIN U51250 10982,100436,CDM,272,RC,,,outpatient,,,8.28,6.21,,6.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.33,6.62,
IV STARTER KIT,100437,CDM,272,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
KERLIX FLUFF 10388,100443,CDM,271,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
KERLIX ROLL,100444,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
KIDNEYSTONE FILTER 10754,100446,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
KIT TRAUMA 8.5FR,100450,CDM,272,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
KLING 1,100452,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
KLING 3  KEND2232-10293,100453,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
KLING 4  CONFORMING GAUZE,100454,CDM,271,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
KLING 6  CONFORMING GAUZE,100455,CDM,271,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
LANCING DEVICE GLUCOLET 11094,100458,CDM,272,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
LEMON GLYC SWABS 10104/11629,100461,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
DO NOT ORDER LEVINE TUBE 12FR,100462,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
LIMB HOLDERS NON243074,100466,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DO NOT USE,100471,CDM,272,RC,,,outpatient,,,942,706.5,,753.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,518.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,379.06,753.6,
LINEN SAVER (BLUE),100472,CDM,271,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
LINEN SAVER (PINK),100473,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
FULL BODY QUILT,100474,CDM,271,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
KY LUBRICANT 5GR SURGILUBE,100480,CDM,271,RC,,,outpatient,,,18.5,13.88,,14.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.44,14.8,
LUKI ASPIRATING TUBE 10537-38,100481,CDM,270,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
LUMBAR PUNC TRAY-ADULT 10588/11545,100483,CDM,272,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
LUMBAR PUNC TRAY-INFANT KC7039-10732,100484,CDM,272,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
LUMBAR PUNC TRAY-PED KC1048-10963,100485,CDM,272,RC,,,outpatient,,,63.9,47.93,,51.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.71,51.12,
MASK FACE SZ 2 (1122),100490,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
MASK RESPIRATOR N95/1860 STANDARD,100494,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
MASK RESPIRATOR N95/9010,100495,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
MAXI PADS,100497,CDM,271,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DIAPERS X LARGE ADULT,100500,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
CUFF DISP BP CHILD,100501,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CUFF DISP BP INFANT,100502,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CAP 3M CUROS TIP MALE LUERS,100503,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
CUFF DISP BP XL ADULT,100505,CDM,270,RC,,,outpatient,,,9.23,6.92,,7.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.71,7.38,
NASAL CANNULA,100508,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BLADE LOPRO S1 GLIDESCOPE,100509,CDM,270,RC,,,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.85,83.2,
BLADE LOPRO S3 (SW),100510,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
BLADE LOPRO MAC S3,100511,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
STYLET GLIDERITE RIGID,100512,CDM,270,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NEEDLE FILL,100513,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
BLADE LOPRO S2,100516,CDM,270,RC,,,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.85,83.2,
BLADE LOPRO S2.5,100517,CDM,270,RC,,,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.85,83.2,
BLADE MILLER S1,100518,CDM,270,RC,,,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.85,83.2,
TRAY 16FR COUDE CATHETER,100520,CDM,270,RC,,,outpatient,,,78.6,58.95,,62.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.63,62.88,
TRAY 18FR COUDE CATHETER,100521,CDM,270,RC,,,outpatient,,,78.6,58.95,,62.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.63,62.88,
TRAY 8FR PEDIATRIC CATHETER,100522,CDM,270,RC,,,outpatient,,,47.04,35.28,,37.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.93,37.63,
KING VISION #2 NON-CHANNELED,100523,CDM,270,RC,,,outpatient,,,27.9,20.93,,22.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.23,22.32,
BLADE LOPRO S4 (GLIDESCOPE),100524,CDM,270,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
BLANKET STRYKER UPPER BODY,100525,CDM,270,RC,,,outpatient,,,9.98,7.49,,7.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,7.98,
BLANKET STRYKER LOWER BODY,100526,CDM,270,RC,,,outpatient,,,9.98,7.49,,7.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,7.98,
OP-SITE 3 7/8-5 1/2,100527,CDM,272,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
OP-SITE 9 3/4-11,100528,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
DO NOT ORDER OSTOMY BELT 11365,100531,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
OSTOMY CARE POWDER 11325,100532,CDM,270,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
OSTOMY DRAIN CLAMP 11305,100533,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
CUFF DISP BP SMALL ADULT,100534,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
OSTOMY PASTE,100535,CDM,270,RC,,,outpatient,,,45.6,34.2,,36.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.35,36.48,
WAFER OSTOMY 2 3/4 HL14204,100536,CDM,271,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
OSTOMY POUCH ALL STANDARD 401510,100537,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DIAPERS 2XL/3XL ADULT,100538,CDM,270,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
PUREWICK FEMALE EXTERNAL CATHETER,100541,CDM,270,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
DO NOT ORDER OXISENSOR PEDIATRIC 10902,100542,CDM,270,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
PUREWICK MALE EXTERNAL CATH,100543,CDM,270,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
RESTRAINT HAND/MITTEN HOOK&LOOP,100544,CDM,270,RC,,,outpatient,,,36.42,27.32,,29.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.66,29.14,
GAUZE PLAIN PACKING 1 X 5,100554,CDM,270,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
PEG TUBE 16FR REPLACEMENT,100563,CDM,270,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
PERINEAL WASH-10237,100571,CDM,271,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
PILLOW REUSABLE 11299,100574,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
DONT USE POSEY VEST-10733-35 MDT821024,100577,CDM,271,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
ISOSORB LTS-PLUS SOLIDIFIER,100582,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DO NOT ORDER PREP SHAVE KIT 10730,100584,CDM,270,RC,,,outpatient,,,4.8,3.6,,3.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.93,3.84,
NO LONGER USE PRO PADZ PACING N11105,100590,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PROBE COVER THERMOSCAN 10162,100591,CDM,270,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
SALEM SUMP TUBE 18FR,100615,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
SALEM SUMP VALVE SHER266197-10240,100616,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
DONT USE SHOE ROCKER CAST LARGE,100628,CDM,270,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
SKIN MARKER,100634,CDM,271,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
AMSORB PLUS CANISTER,100638,CDM,270,RC,,,outpatient,,,23.5,17.63,,18.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,18.8,
SPECI-PAN DYDD36600-10095,100651,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SPONGE IV WICK 2X2 11341,100653,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SPONGE 4X4 16 PLY,100654,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SPONGE DISSECTOR 30-115,100655,CDM,272,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
SPONGE DRAIN 7086-,100656,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SPONGE LAP 18 X 18,100659,CDM,272,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
SPONGE RAY-TEX JJ2515-10471,100661,CDM,272,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
SPONGE SUPER 6X6 10512,100664,CDM,272,RC,,,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
STAPLER REMOVER SKIN ETHPSX-10712,100670,CDM,272,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
STAPLER SKIN ER 10895,100671,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
STAPLES SKIN 10652,100674,CDM,272,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
STERI STRIP-10857,100678,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DONT USE STOCKINETTE ALL STANDARD,100679,CDM,272,RC,,,outpatient,,,40.65,30.49,,32.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.36,32.52,
DO NOT ORDER STOMACH EVACUATOR,100689,CDM,270,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
STOPCOCK 4-WAY 11171 2C6229,100695,CDM,272,RC,,,outpatient,,,12.8,9.6,,10.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.15,10.24,
STOPCOCK 4-WAY 11172 91045,100697,CDM,272,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
SUCTION CANNISTER 65651-515-10086,100707,CDM,272,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
SUCTION CATH 8 FR,100708,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUCTION HANDLE YANKAUER DC3487-10591,100718,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
SUCTION TIP POOLE,100726,CDM,270,RC,,,outpatient,,,8.75,6.56,,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.52,7,
SUCTION TUBE YANKAUER,100728,CDM,272,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
SURGICAL CLIPPER,100735,CDM,270,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
SURGIPAD/ABD,100740,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUTURE PER NEEDLE-SURGERY,100755,CDM,272,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
SUTURE TIES-PACK SURGERY,100757,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SYRINGE L.LOCK 10ML,100770,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SYRINGE L.LOCK 1ML,100771,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SYRINGE L.LOCK 20ML,100772,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SYRINGE L.LOCK 30/35ML,100773,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
SYRINGE L.LOCK 5/6ML,100775,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SYRINGE CATHETER TIP 60ML,100776,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
DO NOT USE SYRINGE ASEPTO,100777,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
SYRINGE BULB EAR,100779,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
SYRINGE IRRIGATION 60ML ASEPTO,100782,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
TEGADERM 2X3 M1624W,100790,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
TEGADERM 4X4 M1626W,100791,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
TELFA 8X3  1238,100794,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
TELFA 4 X 8,100795,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
THORACENTESIS TRAY W/ASPIR 5014-10731 KC,100801,CDM,272,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
THORACENTESIS TRAY W/CATH 4341B-10408,100802,CDM,272,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
TRACH CARE KIT 10722/10684 4681A,100808,CDM,272,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
TRACH TUBE UNCUFFED 9MM,100817,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE UNCUFFED 6MM,100818,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE UNCUFFED 7MM,100819,CDM,272,RC,,,outpatient,,,172,129,,137.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.21,137.6,
TRACH TUBE UNCUFFED 8MM,100820,CDM,272,RC,,,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,148.8,
TRAY 16FR CATHETER,100825,CDM,272,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
TRAY LACERATION STERILE,100828,CDM,272,RC,,,outpatient,,,44.5,33.38,,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.91,35.6,
TRAY PREP 139083-10887,100831,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
TRAY SPINAL ANESTHESIA,100833,CDM,272,RC,,,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
TRAY SUTURE REMOVAL,100834,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
TRAY WET/GEL SKIN SCRUB,100835,CDM,272,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
DELTASONE 20 mg TAB,3200217,CDM,637,RC,J7512,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TROCAR 11MM CO667,100844,CDM,271,RC,,,outpatient,,,111,83.25,,88.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.67,88.8,
TROCAR CATH KIT 12FR,100852,CDM,272,RC,,,outpatient,,,127.5,95.63,,102,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.31,102,
ENDOTRACHEL TUBE 2.0,100859,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
TUBE FEEDING DOBHOFF 8FR 11510 84-710842,100862,CDM,270,RC,,,outpatient,,,25.5,19.13,,20.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.26,20.4,
DO NOT ORDER TUBE FEEDING INFANT,100863,CDM,272,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
TUBE NASOPHARYNGEAL 32 FR,100868,CDM,272,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
TUBE RECTAL 11627,100870,CDM,270,RC,,,outpatient,,,26.8,20.1,,21.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.78,21.44,
TUBING ARGYLE BUBBLE ROLL,100877,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
TUBING BUBBLE STERILE,100878,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUCTION TUBING CONNECTOR,100880,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
TUBING IVAC NTG,100882,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
URINE METER (DO NOT ORDER),100895,CDM,270,RC,,,outpatient,,,27.5,20.63,,22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.07,22,
VALLEY LAB CORD PENCIL/USAGE,100902,CDM,271,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
PATIENT RETURN ELECTRODES,100904,CDM,271,RC,,,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,44,
VALVE LOPEZ 11461,100907,CDM,272,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
DO NOT ORDER VASELINE GAUZE TUBE,100911,CDM,272,RC,,,outpatient,,,11.5,8.63,,9.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.63,9.2,
VENODYNE DAILY USAGE,100915,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
WASH BASIN NO CHARGE,100924,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
IV-1/2 NSS KCL 20 1000ML,100999,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NASOPHANYNGEAL AIRWAY 30F,101000,CDM,270,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BERMAN AIRWAY 80MM,101001,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BERMAN AIRWAY 70MM,101002,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BERMAN AIRWAY 60MM,101003,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BERMAN AIRWAY 40MM,101004,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BERMAN AIRWAY 43MM,101006,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BERMAN AIRWAY 100MM,101007,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
DRAINAGE BAG 4000CC,101008,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
BLADES SURGICAL #11,101009,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
BLADES SURGICAL #15,101010,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SCALPEL DISPOSABLE #11,101011,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SCALPEL DISPOSABLE #15,101012,CDM,272,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
DO NOT USE SCRUB BRUSHES ANCHOR,101013,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CATH COUDE 16FR (BULB),101014,CDM,272,RC,,,outpatient,,,65.5,49.13,,52.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.36,52.4,
DONT USE CATHETER FOLEY 12FR 5CC/COUDE,101015,CDM,272,RC,,,outpatient,,,65.5,49.13,,52.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.36,52.4,
DONT USE KIT PEDIATRIC CATH FR,101016,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
CATH COUDE TIP 14FR 10114,101018,CDM,272,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
CATH COUDE FOLEY 18FR 2WA 0102L18,101019,CDM,272,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
CATH COUDE FOLEY 20FR 2WA 0102L20,101020,CDM,272,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
CATH COUDE 14FR (BULB),101023,CDM,272,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
DO NOT ORDER CATH COUDE FOLEY 20FR 3WA,101024,CDM,272,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
DO NOT ORDER CATH FOLEY SHORT TIP 18FR,101026,CDM,272,RC,,,outpatient,,,60.5,45.38,,48.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.35,48.4,
CATH FOLEY 12FR 5CC 0165L12,101027,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 8FR,101028,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 14FR 5CC,101029,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 18FR 5CC,101030,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
DO NOT ORDER CATH FOLEY 20FR 5CC,101031,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 14FR LATEX FREE,101032,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 24FR,101033,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 18FR,101034,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
DO NOT ORDER CATH FOLEY 24FR 30CC,101035,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 16FR,101036,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CATH FOLEY 22FR,101037,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
THORACIC CATH STRAIGHT 36FR,101038,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
THORACIC CATH STRAIGHT 16FR,101039,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
THORACIC CATH STRAIGHT 24FR,101040,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
THORACIC CATH STRAIGHT 12FR,101041,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
THORACIC CATH STRAIGHT 32FR,101042,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
THORACIC CATH STRAIGHT 40FR,101043,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
DO NOT ORDER CATHETER 12FR I&O RED RUB,101044,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CATHETER 14FR I&O RED RUB,101045,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CATHETER 16FR I&O RED RUB,101046,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
DO NOT ORDER CATH URETHAL 18FR  ALL PURP,101047,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
COLDPACK INSTANT,101050,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
DO NOT USE HEEL/ELBOW PROTECTORS,101051,CDM,271,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
"STOCKING THIGH LARGE, REG",101052,CDM,271,RC,,,outpatient,,,21.53,16.15,,17.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.66,17.22,
STOCKING THIGH XLG LONG,101053,CDM,271,RC,,,outpatient,,,20.19,15.14,,16.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.12,16.15,
STOCKING THIGH SMALL SH,101054,CDM,271,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
STOCKING THIGH SMALL REG,101055,CDM,271,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
STOCKING THIGH SMALL LONG,101056,CDM,271,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
STOCKING THIGH MEDIUM SHORT,101057,CDM,271,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
STOCKING THIGH MEDIUM REG,101058,CDM,271,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
STOCKING THIGH MEDIUM LONG,101059,CDM,271,RC,,,outpatient,,,24.44,18.33,,19.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.83,19.55,
DO NOT ORDER PENROSE DRAIN 5/8  X 18,101060,CDM,271,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
PENROSE DRAIN 1/2  X 18,101062,CDM,271,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
TUBULAR ELASTIC DRESSING GL-705,101063,CDM,272,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
DO NOT ORDER  ELECTRODES OVAL FOAM SOL,101064,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
FACE MASK SZ 5 (1055),101065,CDM,270,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
INTUBATING STYLETS 14FR,101068,CDM,272,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
INTUBATING STYLETS 8FR 103005,101069,CDM,272,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
SET CLEARLINK EXT.,101071,CDM,272,RC,,,outpatient,,,8.28,6.21,,6.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.33,6.62,
KLING 2 STERILE ROLL CONFORMING GAUZE,101072,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
DO NOT ORDER LEVIN TUBE 16FR,101073,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DO NOT ORDER LEVIN TUBE 14FR,101074,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DO NOT ORDER LEVIN TUBE 18FR,101075,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DO NOT ORDER MONTGOMERY STRAP,101076,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
LUKI TUBES 3 1/4,101077,CDM,270,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
MASK BUBBLE GUM TODDLER SZ 3,101078,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
MASK SZ 6 LRG ADULT ANESTHESIA,101079,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
POUCH OSTOMY DRAINABLE 1 SQUIBB401511,101080,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
WAFERSTOMAHESIVE 1 1/4,101081,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
POUCH OSTOMY CLOSED 1 3/4,101082,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
POUCH OSTOMY 2 3/4  DRAIN,101083,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
WAFER OSTOMY POUCH 2 1/4,101084,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
POUCH OSTOMY DRAINABLE 2,101085,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
WAFER OSTOMY 1 1/2,101086,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
OSTOMY POUCH 1 3/4,101087,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
POUCH OSTOMY 1 PIECE CUT,101088,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DONT USE OXISENSOR ADULT NELLCOR NEONATE,101089,CDM,270,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
PEG TUBE 18FR REPLACEMENT,101090,CDM,270,RC,,,outpatient,,,207,155.25,,165.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,83.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,83.3,165.6,
PEG TUBE 20FR REPLACEMENT,101091,CDM,270,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
PEG TUBE 24FR REPLACEMENT,101092,CDM,270,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
PEG TUBE 22FR REPLACEMENT,101093,CDM,270,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
POSEY VEST MEDIUM MDT821022,101094,CDM,271,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
DO NOT ORDER POSEY VEST SMALL MDT828020,101095,CDM,271,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
SALEM SUMP TUBE 14FR,101096,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
SALEM SUMP TUBE 10FR,101097,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
SALEM SUMP TUBE 12FR,101098,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
SALEM SUMP TUBE 16FR,101099,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
SALEM SUMP TUBE 8FR,101100,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
DONT USE SHOE ROCKER CAST MEDIUM,101101,CDM,270,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
DONT USE SHOE ROCKER CAST XL,101102,CDM,270,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
STAPLER SKIN DISPOSABLE DS-5,101103,CDM,272,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
STERI-STRIP 1/8 R1540,101104,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
STERI-STRIP 1/4 X3 R1541,101105,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
STERI-STRIP 1/4 X 1-1/2,101106,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
STOCKINETTE 4  TUBULAR NON-STERILE,101107,CDM,272,RC,,,outpatient,,,40.65,30.49,,32.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.36,32.52,
STOCKINETTE 2  TUBULAR NON-STERILE,101108,CDM,272,RC,,,outpatient,,,40.65,30.49,,32.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.36,32.52,
STOCKINETTE 3  TUBULAR NON-STERILE,101109,CDM,272,RC,,,outpatient,,,40.65,30.49,,32.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.36,32.52,
DO NOT ORDER LAVACUATOR STOMACH EVAC 28F,101110,CDM,270,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
SUCTION CATHETER 10FR STE,101111,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUCTION CATHETER 16FR.,101112,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUCTION CATHETER 18FR,101113,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUCTION CATHETER 14FR STE,101114,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUCTION CATHETER 12FR,101115,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SUCTION CATHETER 14FR,101116,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
TUBING CONNECT SUCTION UNIV 516500,101117,CDM,272,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
SYRINGE INSULIN 1/2ML 29G 1/2,101118,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SYRINGE L.LOCK 3ML,101119,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
SYRINGE L.LOCK 60ML,101120,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
TELFA 4x3 KC1050,101121,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
TRACH TUBE UNCUFFED 4MM PEDIATRIC,101123,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE UNCUFFED 5MM PEDIATRIC,101124,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE CUFFED 4MM PEDIATRIC,101125,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE CUFFED 5MM PEDIATRIC,101126,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE CUFFED 6MM,101127,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE CUFFED 7MM,101128,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE CUFFED 8MM,101129,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE CUFFED 10MM,101130,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRACH TUBE CUFFED 9MM,101131,CDM,272,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
TRAY 18FR CATHETER,101132,CDM,272,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
TRI-LUMEN CVC KIT 7FR 30CM,101133,CDM,272,RC,,,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,163.2,
TRI-LUMEN CVC KIT PED 5FR,101134,CDM,272,RC,,,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,163.2,
TRI-LUMEN CVC KIT 7FR 20CM,101135,CDM,272,RC,,,outpatient,,,400.5,300.38,,320.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,161.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,161.16,320.4,
TROCAR CATH KIT 28 FR,101136,CDM,272,RC,,,outpatient,,,127.5,95.63,,102,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.31,102,
ENDOTRACHEL TUBE 8.0 CUFFED,101137,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 2.5,101138,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 3.5 CUFFED,101139,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 5.5 CUFFED,101140,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 3.0 CUFFED,101141,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 4.0 CUFFED,101142,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 4.5 CUFFED,101143,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 5.0 CUFFED,101144,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 6.0 CUFFED,101145,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 6.5 CUFFED,101146,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 8.5 CUFFED,101147,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 7.5 CUFFED,101148,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 7.0 CUFFED,101149,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
ENDOTRACHEL TUBE 9.0 CUFFED,101150,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
FEEDING TUBE WITH STYLET,101151,CDM,272,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NASAL AIRWAY 8.5,101152,CDM,272,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
IV-SECONDARY SET,101153,CDM,270,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
DO NOT USE IV-PRIMARY ALARIS PUMP SET,101154,CDM,270,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
IV-J-LOOP EXTENSION SET,101155,CDM,270,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
IV-CONNECTOR CLAVE INJECT,101156,CDM,270,RC,,,outpatient,,,4.32,3.24,,3.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.74,3.46,
IV-NITRO SET TUBING,101157,CDM,270,RC,,,outpatient,,,12.04,9.03,,9.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.84,9.63,
IV-BLOOD SET,101158,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV-CATH 20G X 1  PINK,101159,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
IV-CATH 18GA X 1.16  GREEN,101160,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
IV-CATH 24X.75 YELLOW,101161,CDM,270,RC,,,outpatient,,,3.12,2.34,,2.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.26,2.5,
PADDING CAST/SPLINT 6,101165,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
INFUSION SETS 20GX1-1/2,101169,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
INFUSION SETS 20GX1 HUBER,101170,CDM,270,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
HYDROGEN PEROXIDE 4 OZ HDX-10,101171,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
IV-VIAL ACCESS SPIKE,101172,CDM,270,RC,,,outpatient,,,9.82,7.37,,7.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.95,7.86,
SPECIMEN STERILE 4OZ,101175,CDM,270,RC,,,outpatient,,,0.69,0.52,,0.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.28,0.55,
ARMBOARDS MED/SHORT 3X9,101181,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
IV-STERILE WATER 1000ML IRRIGATION,101183,CDM,270,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
IV-D5W 1/2 K40 1000ML,101184,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV-D5W NSS 1000ML,101185,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
IV-D5W 1000ML,101186,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV-STERILE WATER 500ML  IRRIGATION,101187,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
IV-D5W 500ML,101188,CDM,270,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
IV-D5W 250ML,101189,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV-D5W LACTATED RINGERS 1000ML,101190,CDM,270,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
IV-10% DEXTROSE 1000ML,101192,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV-D5W NSS 500ML,101193,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
IV-1/2 NSS 1000ML,101194,CDM,270,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
IV-10% DEXTROSE 500ML,101195,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
IV-D5W 1/2 NSS K20 1000ML,101196,CDM,270,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
IV-NSS 500ML,101198,CDM,270,RC,,,outpatient,,,2.64,1.98,,2.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.06,2.11,
IV-LACTATED RINGER 1000ML,101199,CDM,270,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
IV-D5W 1/2 NSS K30 1000ML,101202,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV-NSS 1000ML,101204,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV-D5W 1/2 NSS 1000ML,101206,CDM,270,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
IV-NSS IRRIGATION 1000ML,101208,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
IV-NSS 250ML,101209,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
IV-D5W 1/2 NSS 500ML,101211,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
IV-NSS 50ML,101214,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
IV-NSS 100ML,101215,CDM,270,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
IV-CATH 22GX1 BLUE,101219,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
SPLINT WRIST PADDED LT SMALL,101221,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SPLINT WRIST PADDED RT SMALL,101222,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
IV-PRIMARY SET,101223,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
ARMBOARDS SMALL,101227,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
URINAL W/HILL-ROM MALE DYND80235S,101228,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
ARMBOARD LONG,101231,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
EGGCRATE BLUE 11111,101325,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
DELTASONE 5MG,3200218,CDM,637,RC,J7512,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BIOPATCH DISK,101327,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
CHLORAPREP,101328,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
STATLOCC PICC,101329,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
AQUA K PADS,101330,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
TUBULAR ELASTIC DRESSING GL-219,102063,CDM,272,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
INS HUMULIN 70/30 1 UNIT,3200406,CDM,636,RC,J1815,HCPCS,both,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,1,
LEVEMIR 100U/ML INJ  1 UNIT,3200464,CDM,636,RC,J1815,HCPCS,both,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,1,
PREDNISONE 1MG TAB,3200687,CDM,637,RC,J7512,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Albuterol 0.5% 0.5mg/ml 20ml,3201072,CDM,250,RC,J7611,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ALBUTEROL 1.25MG/3ML PED,3201638,CDM,636,RC,J7613,HCPCS,both,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,1,
HUMULIN R  1 UNIT,3201721,CDM,636,RC,J1815,HCPCS,both,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,1,
DEXAMETHASONE 0.75MG TAB,3202141,CDM,637,RC,J8540,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NOVOLOG INJECTION 100U/ML,3202597,CDM,636,RC,J1815,HCPCS,both,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,1,
ANOSCOPE DIAGNOSTIC,400002,CDM,490,RC,,,outpatient,,,929,696.75,,743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,373.83,743.2,
HYPAQUE 60%     PER ML.,4000006,CDM,636,RC,Q9961,HCPCS,both,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,1,
ARTHROSCOPY CHARGE,400004,CDM,360,RC,,,outpatient,,,445,333.75,,356,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.07,356,
BONE WAX,400005,CDM,270,RC,,,outpatient,,,14.55,10.91,,11.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.85,11.64,
MOBILITY WALKING CURRENT STATUS,5100559,CDM,420,RC,G8978GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
MOBILITY WALKING CURRENT STATUS,5100560,CDM,430,RC,G8978GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"MOBILITY WALKING, GOAL STATUS",5100561,CDM,420,RC,G8979GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"MOBILITY WALKING, GOAL STATUS",5100562,CDM,430,RC,G8979GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"MOBILITY WALKING, DISCHARGE STATUS",5100563,CDM,420,RC,G8980GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
BX LIVER W/TRU CUT NEEDLE,400011,CDM,490,RC,,,outpatient,,,1173,879.75,,938.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,472.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,586.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,586.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,586.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,586.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,645.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,938.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,472.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,938.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,879.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,938.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,938.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,472.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,938.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,472.02,938.4,
"MOBILITY WALKING, DISCHARGE STATUS",5100564,CDM,430,RC,G8980GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
CHANGING BODY POSITION CURRENT STATUS,5100565,CDM,420,RC,G8981GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
CHANGING BODY POSITION CURRENT STATUS,5100566,CDM,430,RC,G8981GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
CHANGING BODY POSITION GOAL STATUS,5100567,CDM,420,RC,G8982GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
CHANGING BODY POSITION GOAL STATUS,5100568,CDM,430,RC,G8982GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
CHANGING BODY POSITION DISCHARGE STATUS,5100569,CDM,420,RC,G8983GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
COLONOSCOPY,400018,CDM,360,RC,,,outpatient,,,1689,1266.75,,1351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,928.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,679.65,1351.2,
COLONSCOPY DIAG W/TATTOOING,400019,CDM,490,RC,,,outpatient,,,1689,1266.75,,1351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,844.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,928.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,679.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,679.65,1351.2,
CHANGING BODY POSITION DISCHARGE STATUS,5100570,CDM,430,RC,G8983GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"CARRYING OBJECTS, CURRENT STATUS",5100571,CDM,430,RC,G8984GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"CARRYING OBJECTS, GOAL STATUS",5100573,CDM,420,RC,G8985GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"CARRYING OBJECTS, GOAL STATUS",5100574,CDM,430,RC,G8985GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"CARRYING OBJECTS, DISCHARGE STATUS",5100575,CDM,420,RC,G8986GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
"CARRYING OBJECTS, DISCHARGE STATUS",5100576,CDM,430,RC,G8986GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
D&C  NON-OB,400027,CDM,360,RC,,,outpatient,,,2492,1869,,1993.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1002.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1246,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1246,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1246,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1246,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1370.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1993.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1002.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1002.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1993.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1869,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1993.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1993.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1002.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1993.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1002.78,1993.6,
SELF CARE CURRENT STATUS,5100577,CDM,420,RC,G8987GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
SELF CARE CURRENT STATUS,5100578,CDM,430,RC,G8987GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
SELF CARE GOAL STATUS,5100579,CDM,420,RC,G8988GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
SELF CARE GOAL STATUS,5100580,CDM,430,RC,G8988GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
SELF CARE DISCHARGE STATUS,5100581,CDM,420,RC,G8989GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
SELF CARE DISCHARGE STATUS,5100582,CDM,430,RC,G8989GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT FNCTNL LIMIT CURRENT STATUS,5100583,CDM,420,RC,G8990GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT FNCTNL LIMIT CURRENT STATUS,5100584,CDM,430,RC,G8990GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT OR OT FNCTNL LIMIT GOAL STATUS,5100585,CDM,420,RC,G8991GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT OR OT FNCTNL LIMIT GOAL STATUS,5100586,CDM,430,RC,G8991GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT OR OT FNCTNL LIMIT DC STATUS,5100587,CDM,420,RC,G8992GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT OR OT FNCTNL LIMIT DC STATUS,5100588,CDM,430,RC,G8992GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT SUBSEQT LIMIT CURRENT STATUS,5100589,CDM,420,RC,G8993GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT SUBSEQT LIMIT CURRENT STATUS,5100590,CDM,430,RC,G8993GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT SUBSEQT LIMIT GOAL STATUS,5100591,CDM,420,RC,G8994GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT SUBSEQT LIMIT GOAL STATUS,5100592,CDM,430,RC,G8994GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT SUBSEQT LIMIT DC STATUS,5100593,CDM,420,RC,G8995GP,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
OTHER PT/OT SUBSEQT LIMIT DC STATUS,5100594,CDM,430,RC,G8995GO,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,70,
SWALLOWING FUNCTIONAL LIMIT CURRENT STAT,5100595,CDM,440,RC,G8996GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SWALLOWING FUNCTIONAL LIMIT GOAL STATUS,5100596,CDM,440,RC,G8997GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SWALLOWING FUNCTIONAL LIMIT DISCHARGE ST,5100597,CDM,440,RC,G8998GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
MOTOR SPEECH FUNTL LMT CURRENT STATUS,5100598,CDM,440,RC,G8999GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
MOTOR SPEECH FUNTL LMT GOAL STATUS,5100599,CDM,440,RC,G9186GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
MOTOR SPEECH FUNTL LMT DISCHARGE STATUS,5100600,CDM,440,RC,G9158GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SPOKEN LANGUAGE COMP FUNTL LMT CURRENT,5100601,CDM,440,RC,G9159GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SPOKEN LANGUAGE COMP FUNTL LMT GOAL STAT,5100602,CDM,440,RC,G9160GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SPOKEN LANGUAGE COMP FUNTL LMT DISCHARGE,5100603,CDM,440,RC,G9161GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SPOKEN LANG EXPRESS FUNTL LMT CURRENT,5100604,CDM,440,RC,G9162GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SPOKEN LANG EXPRESS FUNTL LMT GOAL,5100605,CDM,440,RC,G9163GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
SPOKEN LANG EXPRESS FUNTL LMT DISCHARGE,5100606,CDM,440,RC,G9164GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
ATTENTION FUNCTIONAL LMT CURRENT STATUS,5100607,CDM,440,RC,G9165GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
ATTENTION FUNCTIONAL LMT GOAL STATUS,5100608,CDM,440,RC,G9166GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
ATTENTION FUNCTIONAL LMT DISCHARGE STATU,5100609,CDM,440,RC,G9167GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
MEMORY FUNCTIONAL LMT CURRENT STATUS,5100610,CDM,440,RC,G9168GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
MEMORY FUNCTIONAL LMT GOAL STATUS,5100611,CDM,440,RC,G9169GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
MEMORY FUNCTIONAL LMT DISCHARGE STATUS,5100612,CDM,440,RC,G9170GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
VOICE FUNCTIONAL LMT CURRENT STATUS,5100613,CDM,440,RC,G9171GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
VOICE FUNCTIONAL LMT GOAL STATUS,5100614,CDM,440,RC,G9172GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
VOICE FUNCTIONAL LMT DISCHARGE STATUS,5100615,CDM,440,RC,G9173GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
OTHER SLP FUNCT LMT CURRENT STATUS,5100616,CDM,440,RC,G9174GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
OTHER SLP FUNCT LMT GOAL STATUS,5100617,CDM,440,RC,G9175GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
OTHER SLP FUNCT LMT DISCHARGE STATUS,5100618,CDM,440,RC,G9176GN,HCPCS,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,60,
HUMULIN R  1 UNIT,6101721,CDM,636,RC,J1815,HCPCS,both,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,1,
ZITHROMAX 250mg TAB,3200962,CDM,637,RC,Q0144,HCPCS,outpatient,,,1.4,1.05,,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.12,
XOPENEX 1.25MG/3ML INH SOLU,3200943,CDM,250,RC,J7614,HCPCS,outpatient,,,1.7,1.28,,1.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.36,
XR CONTRAST-LOW OSMALER PER ML,4000046,CDM,636,RC,Q9967,HCPCS,both,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,2,
EXPLORATORY LAP W/LAPAROSCOPIC ASSIST,400074,CDM,360,RC,,,outpatient,,,5766,4324.5,,4612.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2883,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2883,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2883,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2883,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3171.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2320.24,4612.8,
MOTRIN SUSP 100MG/5ML,6000314,CDM,637,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
FLEX SIG DIAGNOSTIC,400076,CDM,490,RC,,,outpatient,,,1400,1050,,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.36,1120,
FLEX SIG W BX,400077,CDM,490,RC,,,outpatient,,,1400,1050,,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.36,1120,
TYLENOL SUSP160MG/5ML,6000315,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
BENADRYL ELIXIR  25MG/10ML,6000320,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
GASTROSCOPY DIAG,400080,CDM,490,RC,,,outpatient,,,929,696.75,,743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,373.83,743.2,
GASTROSCOPY PEG TUBE/J TUBE PLACEMENT,400081,CDM,490,RC,,,outpatient,,,1072,804,,857.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,589.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,431.37,857.6,
CLONIDINE 0.1 TAB,6000325,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
CLONIDINE .2MG,6000326,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
GI COCKTAIL,6000331,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
XYLOCAINE VISC,6000352,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
MOTRIN SUSP 100MG/5ML,6100526,CDM,637,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
TYLENOL SUSP 160MG/5ML,6100527,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
BENADRYL ELIXIR 25MG /10ML,6100671,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
CLONIDINE 0.1MG TAB,6100673,CDM,250,RC,J8499,HCPCS,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
ZOFRAN ING PER 1MG,6900252,CDM,636,RC,J2405,HCPCS,both,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,2,
ALBUTEROL SUL .0.63MG/3ML SOL,3205548,CDM,636,RC,J7613,HCPCS,both,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2.5,
LIDOCAINE 2%  20MG/ML,6000304,CDM,636,RC,J2001,HCPCS,both,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,3,
LIDOCAINE 2%,6100020,CDM,636,RC,J2001,HCPCS,both,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,3,
INSULIN HUMULIN R 5 UNITS,6300145,CDM,636,RC,J1815,HCPCS,both,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,3,
ROCEPHIN  250 MG INJ,6900104,CDM,982,RC,J0696,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.75,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.66,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,1.8,
DEPO-TESTOSTERONE 200MG/1ML INJ,6900108,CDM,982,RC,J1071,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.05,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.04,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,1.8,
BENADRYL INJ UP TO 50 MG,6900110,CDM,982,RC,J1200,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.36,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.19,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,1.8,
INSULIN HUMULIN R 5 UNITS,6900114,CDM,982,RC,J1815,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,0.9,1.8,
LASIX PER EACH 20MG,6900116,CDM,982,RC,J1940,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.93,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.81,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,1.8,
OR LEVEL 1,400100,CDM,360,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
OR LEVEL 1 PROCUREMENT,400101,CDM,360,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
OR LEVEL 10,400102,CDM,360,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
OR LEVEL 11,400103,CDM,360,RC,,,outpatient,,,1800,1350,,1440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,990,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,724.32,1440,
OR LEVEL 12,400104,CDM,360,RC,,,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
OR LEVEL 13,400105,CDM,360,RC,,,outpatient,,,2250,1687.5,,1800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,905.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1237.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,905.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,905.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1687.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,905.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,905.4,1800,
OR LEVEL 14,400106,CDM,360,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
OR LEVEL 15,400107,CDM,360,RC,,,outpatient,,,2880,2160,,2304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1440,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1440,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1440,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1440,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1584,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1158.91,2304,
OR LEVEL 16,400108,CDM,360,RC,,,outpatient,,,3300,2475,,2640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1815,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1327.92,2640,
OR LEVEL 17,400109,CDM,360,RC,,,outpatient,,,3500,2625,,2800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1925,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1408.4,2800,
OR LEVEL 18,400110,CDM,360,RC,,,outpatient,,,4000,3000,,3200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2200,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1609.6,3200,
OR LEVEL 19,400111,CDM,360,RC,,,outpatient,,,4500,3375,,3600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1810.8,3600,
OR LEVEL 2,400112,CDM,360,RC,,,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,200,
OR LEVEL 2 PROCUREMENT,400113,CDM,360,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
OR LEVEL 20,400114,CDM,360,RC,,,outpatient,,,5000,3750,,4000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2012,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2750,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2012,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2012,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2012,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2012,4000,
OR LEVEL 21,400115,CDM,360,RC,,,outpatient,,,5500,4125,,4400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2213.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3025,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2213.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2213.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2213.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2213.2,4400,
OR LEVEL 22,400116,CDM,360,RC,,,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,4800,
OR LEVEL 3,400117,CDM,360,RC,,,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
OR LEVEL 4,400118,CDM,360,RC,,,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,360,
OR LEVEL 5,400119,CDM,360,RC,,,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,490.4,
OR LEVEL 6,400120,CDM,360,RC,,,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,560,
OR LEVEL 7,400121,CDM,360,RC,,,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,640,
OR LEVEL 8,400122,CDM,360,RC,,,outpatient,,,1023,767.25,,818.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,511.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,511.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,511.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,511.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,411.66,818.4,
OR LEVEL 9,400123,CDM,360,RC,,,outpatient,,,1300,975,,1040,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,523.12,1040,
OSSCILLATING SAWBLADE,400124,CDM,272,RC,,,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.5,98.4,
POWERED LDS,400125,CDM,270,RC,,,outpatient,,,726.3,544.73,,581.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,363.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,363.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,363.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,363.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,399.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,292.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,581.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,292.26,581.04,
RECTAL DILATION,400126,CDM,490,RC,,,outpatient,,,2934,2200.5,,2347.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1180.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1467,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1467,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1467,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1467,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1613.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1180.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1180.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2200.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1180.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1180.64,2347.2,
REMOVAL FB THIGH OR KNEE,400127,CDM,360,RC,,,outpatient,,,2051,1538.25,,1640.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1128.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,825.32,1640.8,
LIDOCAINE 2% 10MG,6900117,CDM,982,RC,J2001,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.05,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.04,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,1.8,
DUONEB NON PAYABLE,6900123,CDM,982,RC,J7620,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.15,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.15,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.15,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.15,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.15,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.15,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.24,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.15,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.21,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.15,1.8,
CLEOCIN 300MG/2ML,6900125,CDM,982,RC,S0077,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,1.8,1.8,
ALBUTEROL NON PAYABLE,6900126,CDM,982,RC,J7611,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.12,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.12,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.19,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.12,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.17,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,1.8,
NITROSTAT 0.4MG,6900196,CDM,982,RC,J8499,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,1.8,1.8,
CLONIDINE 0.1 MG,6900197,CDM,982,RC,J8499,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,1.8,1.8,
CLONIDINE 0.2 MG,6900198,CDM,982,RC,J8499,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,1.8,1.8,
TORADOL 15 MG,6900202,CDM,982,RC,J1885,HCPCS,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.98,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.85,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,1.8,
DEXAMETHASONE 5MG INJ,6900109,CDM,982,RC,J1100,HCPCS,outpatient,,,4,3,,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.21,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.18,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,2.4,
HEPARIN FLUSH 10U/ML SYRINGE (3 ML),3200365,CDM,636,RC,J1642,HCPCS,both,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,4.5,
ROCKY MOUNTAIN SPOTTED FEVER CSF,2801028,CDM,302,RC,86757,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.75,68.36,
PEDIAPRED 15MG/5ML,3200645,CDM,637,RC,J7510,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
STERILE WATER 10ML,3200805,CDM,636,RC,A4218,HCPCS,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
LEVEL 1 ENDO,400141,CDM,360,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
LEVEL 2 ENDO,400142,CDM,360,RC,,,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
LEVEL 3 ENDO,400143,CDM,360,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
LEVEL 1 GENERAL,400144,CDM,360,RC,,,outpatient,,,2800,2100,,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1540,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1126.72,2240,
Hydroxyzine 50mg/ml 1 ml,3201465,CDM,636,RC,J3410,HCPCS,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
LEVEL 2 GENERAL,400146,CDM,360,RC,,,outpatient,,,3800,2850,,3040,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1529.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2090,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2850,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2850,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2850,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2850,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1529.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2850,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1529.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1529.12,3040,
NM PH TC99M PENTETATE PER MCI UPTO 75 MC,4400042,CDM,343,RC,A9567,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NM PH TC99M SODIUM PERTECHNETATE PER MCI,4400045,CDM,343,RC,A9512,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NM TC99M MDP   PER MCI,4400064,CDM,341,RC,A9503,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
STYLET,5200074,CDM,270,RC,94640,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,283.02,
LEVEL 3 GENERAL,400151,CDM,360,RC,,,outpatient,,,4950,3712.5,,3960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2722.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1991.88,3960,
LEVEL 4 GENERAL,400152,CDM,360,RC,,,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,4800,
LEVEL 1 OB/GYN,400153,CDM,360,RC,,,outpatient,,,1540,1155,,1232,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,619.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,770,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,847,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,619.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,619.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1155,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,619.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,619.7,1232,
LEVEL 2 OB/GYN,400154,CDM,360,RC,,,outpatient,,,1800,1350,,1440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,990,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,724.32,1440,
LEVEL 3 OB/GYN,400155,CDM,360,RC,,,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,4800,
LEVEL 4 OB/GYN,400156,CDM,360,RC,,,outpatient,,,8000,6000,,6400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4400,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3219.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3219.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3219.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6400,
LEVEL 5 OB/GYN,400157,CDM,360,RC,,,outpatient,,,9600,7200,,7680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3863.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5280,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3863.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3863.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3863.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7680,
LEVEL 1 PROCEDURE,400158,CDM,360,RC,,,outpatient,,,990,742.5,,792,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,398.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,398.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,398.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,398.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,398.38,792,
LEVEL 2 PROCEDURE,400159,CDM,360,RC,,,outpatient,,,1400,1050,,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.36,1120,
LEVEL 3 PROCEDURE,400160,CDM,360,RC,,,outpatient,,,1600,1200,,1280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,880,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,643.84,1280,
LEVEL 4 PROCEDURE,400161,CDM,360,RC,,,outpatient,,,1900,1425,,1520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1045,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,764.56,1520,
LEVEL 1 TIME,400162,CDM,360,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
LEVEL 2 TIME,400163,CDM,360,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
LEVEL 3 TIME,400164,CDM,360,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
LEVEL 1-CARDIAC,400165,CDM,480,RC,,,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6800,
LEVEL 2-CARDIAC,400166,CDM,480,RC,,,outpatient,,,10000,7500,,8000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4024,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5500,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4024,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4024,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4024,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8000,
LEVEL 3-CARDIAC,400167,CDM,480,RC,,,outpatient,,,15000,11250,,12000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8250,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12000,
HEARING EXAM,6000239,CDM,521,RC,92551,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VISION EXAM,6000251,CDM,521,RC,99173,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
FLEX SIG W BX,401077,CDM,490,RC,,,outpatient,,,1400,1050,,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.36,1120,
DECADRON PER 1MG,6000297,CDM,636,RC,J1100,HCPCS,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
DECADRON 10MG INJ,6100014,CDM,636,RC,J1100,HCPCS,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
DECADRON 10MG/1mL INJ,6100208,CDM,636,RC,J1100,HCPCS,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
HEARING EXAM,6100297,CDM,521,RC,92551,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VISION EXAM,6100307,CDM,521,RC,99173,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CL-HEPARIN FLUSH 10-UNIT,6200043,CDM,636,RC,J1642,HCPCS,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
SENSATRAC SMALL GRANUFOAM DRESSING,490004,CDM,270,RC,,,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.25,84,
SUTURE PROLENE 2/0 30  BLUE,490005,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BANDAGES ESMARK 6,490010,CDM,270,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
CATHETER CHOLANGIOGRAPHY,490014,CDM,270,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
SWEATBANDS FOR SURGERY,490018,CDM,272,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROBE 7 FR FIBER OPTIC URETERAL,490023,CDM,270,RC,,,outpatient,,,1512,1134,,1209.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,608.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,756,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,756,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,756,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,756,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,831.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,608.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,608.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1134,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,608.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,608.43,1209.6,
PUNCH 5000 BIOPSY W/SPK 33CM 5MM,490024,CDM,272,RC,,,outpatient,,,1431.94,1073.96,,1145.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,576.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,715.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,787.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1145.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,576.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1145.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1073.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1145.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1145.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1145.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,576.21,1145.55,
CHOLANGIOGRAPHY CATHETERS,490040,CDM,270,RC,,,outpatient,,,223.82,167.87,,179.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.07,179.06,
GYN VOYANT MARYLAND FUSION DEVICE,490044,CDM,270,RC,,,outpatient,,,680,510,,544,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,374,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,273.63,544,
CATHETER CHOLANGIOGRAM REDDICK SCOOP TIP,490048,CDM,270,RC,,,outpatient,,,326.48,244.86,,261.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.38,261.18,
CLIP APPLIER (HEMOCLIP) SURGERY DR. DUNN,490050,CDM,270,RC,,,outpatient,,,295.96,221.97,,236.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119.09,236.77,
POWER POINT MRI DEVICE KIT,490052,CDM,270,RC,,,outpatient,,,1481.76,1111.32,,1185.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,596.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,740.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,740.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,740.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,740.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,814.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,596.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,596.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1185.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1111.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1185.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,596.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1185.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,596.26,1185.41,
CATHETER CHOLANGIOGRAM REDDICK RIDGID,490053,CDM,270,RC,,,outpatient,,,346.06,259.55,,276.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.25,276.85,
MYOSURE TISSUE REMOVAL SYSTEM (10403FC),490054,CDM,270,RC,,,outpatient,,,2310,1732.5,,1848,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,929.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1270.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,929.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,929.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1732.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,929.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,929.54,1848,
AQUILEX CANNI KIT 36CANS/18TUBES/18SOCKS,490055,CDM,270,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
TRAY WAYNE PNEUMOTHORAX CATHETER SET &,490056,CDM,270,RC,,,outpatient,,,365,273.75,,292,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.88,292,
HEARING EXAM,6300082,CDM,972,RC,92551,HCPCS,outpatient,,,5,3.75,,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,8,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,7,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,3,8,
DILATOR ELIMINATOR 3-STAGE PET ESOPHAGEA,490061,CDM,278,RC,,,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
ANESTHESIA LEVEL II,600001,CDM,370,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
ANETHESIA LEVEL III,600002,CDM,370,RC,,,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,320,
ANESTHESIA LEVEL IV,600003,CDM,370,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
VENTILATOR-ANESTHESIA,600004,CDM,370,RC,,,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
ANESTHESIA/15 MINUTES/FACILITY CHARGE,600005,CDM,370,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
PHENERGAN 25MG INJ,6900119,CDM,982,RC,J2550,HCPCS,outpatient,,,5,3.75,,,,,,other,Not separately reimbursable for physician setting,3.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,3.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,3.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,3.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,3.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,3.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,3.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,5.57,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,3.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,4.87,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,3,5.57,
"VITAMIN B12 UP TO 1,000 MCG",6900121,CDM,982,RC,J3420,HCPCS,outpatient,,,5,3.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.33,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.33,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.33,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.33,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.33,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.33,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.13,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,1.33,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.86,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.33,3,
ROCEPHIN 500 MG INJ,6900190,CDM,982,RC,J0696,HCPCS,outpatient,,,5,3.75,,,,,,other,Not separately reimbursable for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.75,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.66,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,3,
INSULIN HUMULIN R PER INJ,6900200,CDM,982,RC,J1815,HCPCS,outpatient,,,5,3.75,,,,,,other,Not separately reimbursable for physician setting,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,0.9,3,
ANES CLOSED CHEST PROC MEDIA & DIAG THOR,7200007,CDM,370,RC,00528QZ,HCPCS,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
LEVEL 1 ORTHO,800001,CDM,360,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
LEVEL 2 ORTHO,800002,CDM,360,RC,,,outpatient,,,1300,975,,1040,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,523.12,1040,
LEVEL 3 ORTHO,800003,CDM,360,RC,,,outpatient,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,684.08,1360,
LEVEL 4 ORTHO,800004,CDM,360,RC,,,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
KNEE ARTHROSCOPY IV TRAY,890000,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
STOCKINETTE ALL COTTON STERILE,890001,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DRAPE SHOULDER TIBURON BEACH CHAIR,890002,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
U-DRAPE POLY 60 X 60,890003,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
SHEET SPLIT HEAVY DUTY,890004,CDM,270,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
SHEET TIBURON EXTREMITY,890005,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
STOCKINETTE IMPERVIOUS LARGE,890006,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
TEST SUPPLY CHARGE,2800596,CDM,272,RC,99334,HCPCS,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
ADRENALIN 1MG/ML,3200291,CDM,636,RC,J0171,HCPCS,both,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,6,
MAGNESIUM SULFATE 50%(5GRAMS/10ML),3202185,CDM,636,RC,J3475,HCPCS,both,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,6,
NM TC99M SULFUR COLLOID PER 1 mCi,4400046,CDM,343,RC,A9541,HCPCS,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
CRYOSURGERY 2ND - 14TH LESION,6100541,CDM,521,RC,17003,HCPCS,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,112.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,112.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,112.31,
DRILL 4.9 CANNULATED,890017,CDM,272,RC,,,outpatient,,,894.72,671.04,,715.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,447.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,447.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,447.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,447.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,492.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,360.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,715.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,715.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,715.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,360.04,715.78,
VISION EXAM,6300062,CDM,972,RC,99173,HCPCS,outpatient,,,6,4.5,,,,,,other,Not separately reimbursable for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,4.42,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,3.86,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.59,4.42,
TORADOL 30 MG,6900115,CDM,982,RC,J1885,HCPCS,outpatient,,,6,4.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.98,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.85,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,3.6,
NEEDLE ECHOGENIC (PROLONG) ANESTHESIA,890020,CDM,270,RC,,,outpatient,,,27.01,20.26,,21.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.87,21.61,
ATROVENT FOR RESP. 1MG,3200039,CDM,250,RC,J7644,HCPCS,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
STERILE WATER 1000 ML IRRIGATION,3300086,CDM,258,RC,A4217,HCPCS,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
XOPENEX 0.31%/3ML,3200941,CDM,250,RC,J7614,HCPCS,outpatient,,,6.79,5.09,,5.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.73,5.43,
REAMER SHAFT,890045,CDM,270,RC,,,outpatient,,,614.96,461.22,,491.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,338.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,247.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,491.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,247.46,491.97,
GUIDE ROD 3 X 1000,890046,CDM,278,RC,,,both,,,406.7,305.03,,325.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,163.66,406.7,
GAMMA 11 X 180 X 130 DEGREE,890048,CDM,278,RC,,,both,,,2279.54,1709.66,,1823.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,917.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1253.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1139.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1823.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1709.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,917.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,917.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1595.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1709.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1823.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1823.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,917.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1823.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,917.29,1823.63,
XOPENEX 0.63MG/3ML,3200942,CDM,250,RC,J7614,HCPCS,outpatient,,,6.79,5.09,,5.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.73,5.43,
BIOPATH DISK,6200439,CDM,360,RC,99070,HCPCS,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
PULSE OXIMETRY,6900063,CDM,982,RC,94760,HCPCS,outpatient,,,7,5.25,,,,,,other,Not separately reimbursable for physician setting,1.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,3.46,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,2.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,3.02,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.83,4.2,
UNASYN PER 1.5 G,6900102,CDM,982,RC,J0295,HCPCS,outpatient,,,7,5.25,,,,,,other,Not separately reimbursable for physician setting,1.89,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.05,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.05,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.05,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.05,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.89,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.89,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2.05,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.05,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.89,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,3.28,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,2.05,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.87,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.89,4.2,
XOPENEX 1.25MG/0.5ML INH SOLU,3201042,CDM,250,RC,J7612,HCPCS,outpatient,,,7.46,5.6,,5.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,5.97,
STERILE WATER 20mL,3200806,CDM,636,RC,A4216,HCPCS,both,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,7.5,
STERILE WATER 1000 ML IV,3300087,CDM,258,RC,A4217,HCPCS,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
SPEEDGUIDE FOR 3.5MM T10,890058,CDM,270,RC,,,outpatient,,,775.2,581.4,,620.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,387.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,387.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,387.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,311.94,620.16,
DRILL SPEEDGUIDE 2.6MM,890059,CDM,270,RC,,,outpatient,,,409.2,306.9,,327.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,164.66,327.36,
Aminophylline 500mg Inj,3201110,CDM,636,RC,J0280,HCPCS,both,,,7.75,5.81,,6.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.12,7.75,
GLUCOSE STRIP SCC,6000173,CDM,300,RC,82948,HCPCS,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,11.19,
GLUCOSE STRIP,6100223,CDM,300,RC,82948,HCPCS,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,11.19,
BLOOD GLUCOSE (ACCUCHECK0,6300031,CDM,300,RC,82962,HCPCS,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.64,8.26,
GLUCOSE STRIP,6300035,CDM,300,RC,82948,HCPCS,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,11.19,
GLUCOSE STRIP,6900163,CDM,300,RC,82948,HCPCS,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,11.19,
COLLECTION VENOUS BLOOD,6300179,CDM,300,RC,36416,HCPCS,outpatient,,,8.83,6.62,,7.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,7.06,
DRILL,890067,CDM,270,RC,,,outpatient,,,598.8,449.1,,479.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,299.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,299.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,299.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,329.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,240.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,479.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,240.96,479.04,
HOT/COLD PKS TO ONE OR MORE AREAS,5100535,CDM,420,RC,97010GP,HCPCS,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,70,
CALCIUM GLUCONATE 10ML,3200105,CDM,636,RC,J0612,HCPCS,both,,,9.25,6.94,,7.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.72,9.25,
DUONEB HHN (0.5/3mg) (RESPIRATORY),3200268,CDM,250,RC,J7620,HCPCS,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
NARCAN 0.4mg INJ,3200589,CDM,636,RC,J2310,HCPCS,both,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,9.5,
VACCINE  ADMINISTRATION UNDER AGE 18,1400500,CDM,450,RC,90460,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
VACCINE  ADMINISTRATION EA  ADDT'L,1400501,CDM,450,RC,90461,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
PPD SKIN TEST,2800485,CDM,302,RC,86580,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.5,36.88,
SKIN TEST - IPPD,2800564,CDM,302,RC,86580,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.5,36.88,
HEPARIN FLUSH 100U/ML 5mL,3200364,CDM,636,RC,J1642,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
KCL 20MEQ INJ,3200427,CDM,636,RC,J3480,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
KETAMINE 50MG/ML PER ML,3200438,CDM,636,RC,J3490,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
Tuberculin test,3201422,CDM,250,RC,86580,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,36.88,
NM PH AMINOPHYLLINE,4400029,CDM,636,RC,J0280,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
NM PH TC99M SESTAMIBI PER 15 MCI,4400044,CDM,343,RC,A9500,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
STOOL (OCCULT BLOOD) SCC,6000168,CDM,300,RC,82270,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,11.48,
HEMOGLOBIN SCC,6000183,CDM,300,RC,85018,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,8.37,
WET PREP SCC,6000191,CDM,300,RC,87210,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,15.05,
IMMUNIZATION ADMIN EACH,6000198,CDM,521,RC,90472,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
HEWSON RETRIEVER SUTURE,890094,CDM,270,RC,,,outpatient,,,428.57,321.43,,342.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,172.46,342.86,
INJECTION IM/SUBCUTANEOUS,6000246,CDM,521,RC,96372,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,99.71,
ADM OF PNEUM VIRUS VACCINE W/O COUN,6000282,CDM,771,RC,G0009,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,62.61,
INSULIN HUMULIN R 5 UNITS,6000301,CDM,636,RC,J1815,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
POTASSIUM CHLORIDE,6000313,CDM,636,RC,J3480,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
VISTARIL 25MG INJ,6000351,CDM,636,RC,J3410,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
PHENERGAN 25 MG INJ,6000353,CDM,636,RC,J2550,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
ADMIN OF INFL VIRUS VACCINE,6100001,CDM,771,RC,G0008,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,62.61,
POTASSIUM CHLORIDE,6100030,CDM,636,RC,J3480,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
INSULIN HUMULIN R 5 UNITS,6100034,CDM,636,RC,J1815,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
H1N1 MEDCARE ADMINISTRATION,6100039,CDM,250,RC,G9141,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
VISTARIL 25MG INJ,6100106,CDM,636,RC,J3410,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
CLAMP PIN TO ROD HOFFMAN3,890108,CDM,278,RC,,,both,,,1024.1,768.08,,819.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,716.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.1,819.28,
CLAMP ROD TO ROD HOFFMAN3,890109,CDM,278,RC,,,both,,,1024.1,768.08,,819.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,716.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,819.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.1,819.28,
PIN APEX TRANS FIX 4X250,890110,CDM,278,RC,,,both,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,126,
PIN APEX 180MM S/D HALF 50,890111,CDM,278,RC,,,both,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.08,117,
CLAMP 5 HOLE PIN HOFFMANN3,890112,CDM,278,RC,,,both,,,1188,891,,950.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,478.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,653.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,594,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,891,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,891,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,891,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,478.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,478.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,891,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,478.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,478.05,950.4,
ROD 11MM X 350 CARBON HOFFMANN3 CONNECT,890113,CDM,278,RC,,,both,,,570.9,428.18,,456.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,229.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,285.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,229.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,456.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,229.73,570.9,
PADDING WEBRIL UNDERCAST 4X4,890114,CDM,270,RC,,,outpatient,,,2.64,1.98,,2.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.06,2.11,
URINE AUTOMATED WITH MICROSCOPY,6100219,CDM,300,RC,81001,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.58,11.19,
STOOL (OCCULT BLOOD),6100221,CDM,300,RC,82270,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,11.48,
HEMATOCRIT,6100225,CDM,300,RC,85014,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,8.37,
HEMOGLOBIN,6100226,CDM,300,RC,85018,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,8.37,
WET PREP,6100233,CDM,300,RC,87210,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,15.05,
IMMUNIZATION ADMIN EACH,6100258,CDM,521,RC,90472,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
FLU SHOT ADMINISTRATION,6100286,CDM,771,RC,G0008,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,62.61,
KOH PREP,6100433,CDM,300,RC,Q0112,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,12.43,
TUBERCULIN TEST,6100465,CDM,636,RC,86580,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,36.88,
DRAPE HIP WITH POUCHES TIBURON,890127,CDM,270,RC,,,outpatient,,,30.56,22.92,,24.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.3,24.45,
PADDING WEBRIL CAST 6  X 4 YD,890137,CDM,270,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
PHENERGAN 25 MG INJ,6100900,CDM,636,RC,J2550,HCPCS,both,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,10,
DRILL 2.6MM,890139,CDM,278,RC,,,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,318,
SPEED GUIDE,890140,CDM,270,RC,,,outpatient,,,358.8,269.1,,287.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,144.38,287.04,
TUBERCULIN TEST,6101422,CDM,637,RC,86580,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,36.88,
DTAP/HBV/POLIO,6300004,CDM,510,RC,90723,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
DTAP/HIB,6300005,CDM,510,RC,90721,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
HEMO INFLU,6300006,CDM,510,RC,90645,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
HIV/HBV,6300011,CDM,510,RC,90748,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
ROTAVIRUS IMMUNIZATION,6300022,CDM,510,RC,90680,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
THERAPEUTIC INJECTION ADM FEE,6300025,CDM,972,RC,96372,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,16,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,14,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6,16,
THERAPEUTIC INJECTION ADM FEE,6300026,CDM,510,RC,90782,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
HEMATOCRIT,6300036,CDM,300,RC,85014,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,8.37,
HEMOGLOBIN,6300037,CDM,300,RC,85018,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,8.37,
NAIL 9 X 330MM TIBIA,890153,CDM,278,RC,,,both,,,2515.8,1886.85,,2012.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1012.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1383.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1257.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2012.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1886.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1886.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1886.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1886.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1012.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1012.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1761.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1886.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2012.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2012.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1012.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2012.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1012.36,2012.64,
KOH PREP,6300039,CDM,300,RC,Q0112,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,12.43,
STOOL (OCCULT BLOOD),6300046,CDM,300,RC,82270,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,11.48,
WET PREP,6300053,CDM,300,RC,87210,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,15.05,
IMMUNIZATION ADMIN EACH,6300083,CDM,972,RC,90472,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,14,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6,16,
END CAP 45MM,890158,CDM,278,RC,,,both,,,301.34,226.01,,241.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.26,301.34,
DRILL 2.0,890160,CDM,278,RC,,,both,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.58,240,
ADMIN OF INFL VIRUS VACCINE,6300160,CDM,771,RC,G0008,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,62.61,
ADMIN OF PNEUM VIRUS VACCINE,6300161,CDM,771,RC,G0009,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,62.61,
"SCREENING FOR DEPRESSION, POSITIVE",6300191,CDM,972,RC,G8431,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,6,6,
SUICIDE RISK ASSESSED,6300192,CDM,972,RC,3085F,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,6,6,
"SCREENING DEPRESSION; NEGATIVE, NO F/U R",6300195,CDM,972,RC,G8510,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,6,6,
KENALOG PER 10MG,6900120,CDM,982,RC,J3301,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.86,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.62,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.05,6,
SILVADENE CREAM PER APPLICATION,6900122,CDM,982,RC,J3490,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,6,6,
GLUCOSE INSTA,6900124,CDM,982,RC,J8499,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,6,6,
STOOL (OCCULT BLOOD),6900162,CDM,982,RC,82270,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,4.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,4.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,4.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.01,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,4.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,6.13,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,4.38,7.01,
HEMATOCRIT,6900165,CDM,982,RC,85014,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.79,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,3.32,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,6,
CUTTER TOMCAT HC 4.0,890171,CDM,278,RC,,,both,,,173.34,130.01,,138.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.75,173.34,
TUBING INTEGRATED,890172,CDM,278,RC,,,both,,,230.58,172.94,,184.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,92.79,230.58,
DRILL 3.5MM,890173,CDM,278,RC,,,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,318,
HEMOGLOBIN,6900166,CDM,300,RC,85018,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,8.37,
WET PREP,6900172,CDM,982,RC,87210,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5.82,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5.82,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,5.82,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,5.82,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5.82,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,5.82,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.31,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,5.82,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,8.15,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,5.82,9.31,
IMMUNIZATION ADMIN EACH,6900173,CDM,521,RC,90472,HCPCS,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
SCREW 3.5MM NON LOCKING 42MM,890177,CDM,278,RC,C1713,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,869.4,869.4,
ROCEPHIN 1 GM INJ,6900189,CDM,982,RC,J0696,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.75,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.66,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.47,6,
LASIX 40 MG VIAL,6900192,CDM,982,RC,J1940,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.93,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.58,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.81,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.58,6,
LIDOCAINE 2% 50 ML VIAL,6900193,CDM,982,RC,J2001,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.05,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.03,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.04,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.03,6,
BENADRYL  50 MG VIAL,6900199,CDM,982,RC,J1200,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.06,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.36,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.19,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.85,6,
PACK HIP STERILE ORTHOMAX SURGICAL,890182,CDM,272,RC,,,outpatient,,,128.3,96.23,,102.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.63,102.64,
NOZZLE & MED PRESS REVOLUTION CMS W/FEMO,890184,CDM,272,RC,,,outpatient,,,278.33,208.75,,222.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,112,222.66,
MIXEVAC III CEMENT,890185,CDM,272,RC,,,outpatient,,,117.6,88.2,,94.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.32,94.08,
BIO-PREP BONE PREP KIT,890186,CDM,272,RC,,,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,200,
GUN REVOLUTION CEMENT,890187,CDM,272,RC,,,outpatient,,,1696,1272,,1356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,682.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,848,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,848,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,848,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,932.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,682.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,682.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1272,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,682.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,682.47,1356.8,
INTERPULSE HANDPIECE W/HIGH FLOW TIP,890188,CDM,272,RC,,,outpatient,,,75.53,56.65,,60.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.39,60.42,
BLADE PERFORMANCE SERIES SAGITTAL 18X1.2,890189,CDM,272,RC,,,outpatient,,,127.78,95.84,,102.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.42,102.22,
BLADE PERFORMANCE SERIES SAGITTAL 25X1.2,890190,CDM,272,RC,,,outpatient,,,127.78,95.84,,102.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.42,102.22,
FLYTE SURGICOOL HOOD PEELAWAY,890191,CDM,272,RC,,,outpatient,,,85.83,64.37,,68.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.54,68.66,
TOURNIQUET CUFF 18X4 DISP RED,890192,CDM,270,RC,,,outpatient,,,47.98,35.99,,38.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.31,38.38,
TOURNIQUET CUFF 24X4 DISP YELLOW,890193,CDM,270,RC,,,outpatient,,,53.37,40.03,,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.48,42.7,
TOURNIQUET CUFF 30X4 DISP ROYAL BLUE,890194,CDM,270,RC,,,outpatient,,,57.36,43.02,,45.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.08,45.89,
TOURNIQUET CUFF 34X4 DISP PURPLE,890195,CDM,270,RC,,,outpatient,,,61.35,46.01,,49.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.69,49.08,
TOURNIQUET CUFF 44X4 DISP NAVY BLUE,890196,CDM,270,RC,,,outpatient,,,66.63,49.97,,53.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.81,53.3,
PEG EXTENSION 4,890197,CDM,272,RC,,,outpatient,,,340,255,,272,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,136.82,272,
FHC-INJECTION/IM SUBCUTANEOUS,6900209,CDM,982,RC,96372,HCPCS,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,16,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,10,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,14,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6,16,
CLEOCIN 300MG/2ML,3204079,CDM,636,RC,J0736,HCPCS,both,,,10.3,7.73,,8.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.14,10.3,
SKIN TEST - CANDIDA,2800563,CDM,302,RC,86485,HCPCS,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.05,36.88,
TEST FOR URINE CYSTINES,2800595,CDM,301,RC,82615,HCPCS,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.77,28.84,
SCREW 2.7 NON-LOCKING 16MM,890202,CDM,278,RC,,,both,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,186,
NEOSTIGMINE 1MG/ML 10ML,3201136,CDM,636,RC,J2710,HCPCS,both,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,11,
PHLEBOTOMY,2800473,CDM,940,RC,99195,HCPCS,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,171.6,
LAB VENIPUNCTURE ITEM,2800681,CDM,300,RC,36415,HCPCS,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,13.71,
SCREW 3.5 LOCKING 24MM,890206,CDM,278,RC,,,both,,,354,265.5,,283.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.45,354,
ATROPINE INJ 0.4MG/ML,3200038,CDM,636,RC,J0461,HCPCS,both,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,12,
IPPD(TB),6300100,CDM,972,RC,86580,HCPCS,outpatient,,,12,9,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,14.38,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,12.59,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,14.38,
"INFLUENZA TRIVT, SPLIT 6-35 MONTHS",6900030,CDM,982,RC,90657,HCPCS,outpatient,,,12,9,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,7.2,7.2,
FINGER TRAP XSMALL (PEDS),890210,CDM,272,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
FINGER TRAP SMALL,890211,CDM,272,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
FINGER TRAP MEDIUM,890212,CDM,272,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
FINGER TRAP LARGE,890213,CDM,272,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
FINGER TRAP XLARGE,890214,CDM,272,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
EQUALIZER ALLEN,890215,CDM,272,RC,,,outpatient,,,573.8,430.35,,459.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,286.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,230.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,430.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,230.9,459.04,
SERFAS ENERGY 90-S CRUISE,890216,CDM,272,RC,,,outpatient,,,376.58,282.44,,301.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,188.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,151.54,301.26,
PROBES RF 2 50-S,890217,CDM,272,RC,,,outpatient,,,313.4,235.05,,250.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.11,250.72,
TUBING CROSSFLOW INFLOW CASSETTE,890218,CDM,272,RC,,,outpatient,,,134.55,100.91,,107.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.14,107.64,
BLADE TOMCAT SHAVER 4.0MM,890219,CDM,272,RC,,,outpatient,,,173.34,130.01,,138.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.75,138.67,
BLADE BARREL BUR 6 FLUTE F-SERIES-4.0MM,890220,CDM,272,RC,,,outpatient,,,133.38,100.04,,106.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.67,106.7,
CUSHION ARTHREX FOAM INSERT (LEG HOLDER),890221,CDM,272,RC,,,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.65,84.8,
TORADOL 60MG INJ,6900182,CDM,982,RC,J1885,HCPCS,outpatient,,,12,9,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.98,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.61,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.85,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.61,7.2,
KEFZOL 1GM INJ,3200432,CDM,636,RC,J0690,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
MAGNESIUM SULFATE 1gm/2mL INJ,3200532,CDM,636,RC,J3475,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
OXYTOCIN 10 UNITS/ML 1ML,3200640,CDM,636,RC,J2590,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
PHENERGAN 25MG INJ,3200659,CDM,636,RC,J2550,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
PHENOBARBITAL 65MG/ML INJ,3200667,CDM,636,RC,J2560,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,58,
REGLAN 10MG INJ,3200736,CDM,636,RC,J2765,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
NEEDLE CHAMPION PASSER,890229,CDM,272,RC,,,outpatient,,,405.5,304.13,,324.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,202.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,163.17,324.4,
EPINEPHRINE 1 MG/ML AMP,3202014,CDM,636,RC,J0171,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
CELESTONE PER 3MG,6000293,CDM,636,RC,J0702,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
THREADED CANNULA,890232,CDM,272,RC,,,outpatient,,,51.92,38.94,,41.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.89,41.54,
CELESTONE PER 3MG,6100008,CDM,636,RC,J0702,HCPCS,both,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,12.5,
KETAMINE 10MG/ML PER ML,3205668,CDM,636,RC,J3490,HCPCS,both,,,12.75,9.56,,10.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.13,12.75,
HEARING EXAM,6900061,CDM,982,RC,92551,HCPCS,outpatient,,,13,9.75,,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,10.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,17.23,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,10.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,15.08,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6.59,17.23,
ZITHROMAX SUSP 200/5ML 30ML,3200964,CDM,637,RC,Q0144,HCPCS,outpatient,,,13.25,9.94,,10.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.33,10.6,
DOBUTREX 250 MG VIAL,3200258,CDM,636,RC,J1250,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
PINS HEADED THREADED,890238,CDM,278,RC,,,both,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,190,
PINS HEADLESS THREADED (402394),890239,CDM,278,RC,,,both,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,190,
MANNITOL 50ML AMP,3200533,CDM,636,RC,J2150,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
MEPERIDINE 25MG INJ,3200541,CDM,636,RC,J2175,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
MEPERIDINE 50MG/1mL INJ,3200542,CDM,636,RC,J2175,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
MEPERIDINE 75MG INJ,3200544,CDM,636,RC,J2175,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
NUBAIN INJ 10MG,3200630,CDM,636,RC,J2300,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
Lidocaine 2% 20mg/ml,3201267,CDM,636,RC,J2001,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
WATERBUG FLOOR SUCTION DEVICE,890246,CDM,270,RC,,,outpatient,,,84.58,63.44,,67.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.03,67.66,
DRESSING AQUACEL SURGICAL,890247,CDM,272,RC,,,outpatient,,,74.1,55.58,,59.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.82,59.28,
DEMEROL 100MG/ML,3204212,CDM,636,RC,J2175,HCPCS,both,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,13.5,
BANDAGE STERILE 4  ELASTIC SELF-CLOSE,890249,CDM,272,RC,,,outpatient,,,1.85,1.39,,1.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.74,1.48,
BANDAGE STERILE 6  ELASTIC SELF CLOSE,890250,CDM,272,RC,,,outpatient,,,2.67,2,,2.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.07,2.14,
DILANTIN 100MG INJ,3200244,CDM,636,RC,J1165,HCPCS,both,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,14,
MAXIPIME 1 GRAM INJ,3201773,CDM,636,RC,J0692,HCPCS,both,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,14,
D5NS 1000ML,3300058,CDM,636,RC,J7042,HCPCS,both,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,14,
INTRODUCER AVANTI STANDARD SHEATH,5890070,CDM,278,RC,C1894,HCPCS,both,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,14,
XBRAID-TT 2.0 MM,890255,CDM,272,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
FIBER #2 FORCE,890256,CDM,272,RC,,,outpatient,,,37.44,28.08,,29.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.07,29.95,
COUNTERSINK,890257,CDM,272,RC,,,outpatient,,,248.4,186.3,,198.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.96,198.72,
DEPO-MEDROL 40MG INJ,6900106,CDM,982,RC,J1030,HCPCS,outpatient,,,14,10.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,7.2,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,7.2,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.52,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,7.2,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.08,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,7.2,11.52,
DECADRON 10MG/1mL INJ,3200208,CDM,636,RC,J1100,HCPCS,both,,,14.4,10.8,,11.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.79,14.4,
HEMATOCRIT,2800329,CDM,305,RC,85014,HCPCS,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,11.6,
HEMOGLOBIN,2800348,CDM,305,RC,85018,HCPCS,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,11.6,
HYDROMORPHONE 2MG INJ,3200380,CDM,636,RC,J1170,HCPCS,both,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,14.5,
LIDOCAINE 100MG,3200475,CDM,636,RC,J2001,HCPCS,both,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,14.5,
SOLU MEDROL 40MG,3200796,CDM,636,RC,J2920,HCPCS,both,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,14.5,
HYDROMORPHONE 1 MG/ML,3204505,CDM,636,RC,J1170,HCPCS,both,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,14.5,
HGB SCC,6000184,CDM,305,RC,85018,HCPCS,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,11.6,
HGB,6100425,CDM,305,RC,85018,HCPCS,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,11.6,
CUTTER TOMCAT HC 3.5,890268,CDM,270,RC,,,outpatient,,,173.34,130.01,,138.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.75,138.67,
TUBING SCOPE (ORTHO),890269,CDM,270,RC,,,outpatient,,,14.55,10.91,,11.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.85,11.64,
WAND 90 DEGREE SERFAS ENERGY,890270,CDM,270,RC,,,outpatient,,,358.76,269.07,,287.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,144.37,287.01,
URINALYSIS W/ AUTOMATED,2800005,CDM,300,RC,81003,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,12,
URINALYSIS REPEAT,2800978,CDM,300,RC,8100391,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
PH STOOL,2801030,CDM,302,RC,83986,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.79,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,12.64,
RPR TITER ADDON CPT,2801049,CDM,305,RC,86593,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.2,15.57,
BUN BODY FLUID,2801313,CDM,301,RC,84540,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.78,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.78,16.43,
URINE DIP,2801332,CDM,300,RC,81002,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.74,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.74,12,
SFMC  RPR PEDS OR TREATMENT,2801363,CDM,307,RC,86592,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,15.05,
MORPHINE 4MG INJ,3200568,CDM,636,RC,J2270,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
SUBLIMAZE 0.1mg/2mL INJ,3200807,CDM,636,RC,J3010,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
Morphine 2 MG INJ,3201329,CDM,636,RC,J2270,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
AMIODARONE HCL IV SOLUTION 50MG/1ML,3202712,CDM,636,RC,J0282,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
DRILL 2.0,890283,CDM,278,RC,,,both,,,326.58,244.94,,261.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.42,326.58,
BUTORPHANOL TAR. 1MG/ML,3204567,CDM,636,RC,J0595,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
ANGIO CATH UNIT,3300003,CDM,278,RC,C1751,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
ABG KIT,5200007,CDM,270,RC,82803,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,41.71,
AEROSOL MASK,5200009,CDM,270,RC,82803,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,41.71,
AEROSOL T ADAPTER,5200010,CDM,270,RC,82803,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,41.71,
URINALYSIS SCC,6000164,CDM,300,RC,81000,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,12,
URINE DIP SCC,6000165,CDM,300,RC,81002,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.74,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.74,12,
URINALYSIS SCC,6000166,CDM,300,RC,81003,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,12,
TUBERCULIN SKIN TEST SCC,6000189,CDM,636,RC,86580,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,36.88,
..TESTING ONLY FOLATE DO NOT ORDER,989898,CDM,123,RC,,,inpatient,,,,,,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,2737.25,
RECOVERY ROOM LEVEL II 1ST 30 MIN,1000001,CDM,710,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
RECOVERY ROOM LEVEL II EAC ADDL 15 MIN,1000002,CDM,710,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
RECOVERY ROOM LEVEL III 1ST 30 MIN,1000003,CDM,710,RC,,,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,320,
RECOVERY ROOM LEVEL III EA ADDL 15 MIN,1000004,CDM,710,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
RECOVERY ROOM LEVEL IV 1ST 30 MIN,1000005,CDM,710,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
RECOVERY ROOM LEVEL IV EA ADDL 15 MIN,1000006,CDM,710,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
RECOVERY SERVICES 1ST 30 MIN,1000007,CDM,710,RC,,,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
RECOVERY SERVICES OVER 30 MIN,1000008,CDM,710,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
RECOVERY SERVICES PER MINUTE,1000009,CDM,710,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
ROCEPHIN 250 MG INJ,6000292,CDM,636,RC,J0696,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
"VITAMIN B12 UP TO 1,000 MCG",6000312,CDM,636,RC,J3420,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
TUBERCULIN TEST,6000350,CDM,636,RC,86580,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,36.88,
TESTOSTERONE CYPIONATE 1MG INJECTION,6000363,CDM,636,RC,J1071,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
ROCEPHIN 250 MG INJ,6100026,CDM,636,RC,J0696,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
"VITAMIN B12 UP TO 1,000 MCG",6100029,CDM,636,RC,J3420,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
H1N1 MEDICARE VACCINE,6100040,CDM,250,RC,G9142,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
URINALYSIS NELHC,6100218,CDM,300,RC,81000,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,12,
URINE DIP,6100220,CDM,300,RC,81002QW,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
PROTHROMBIN TIME,6100228,CDM,300,RC,85610,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.14,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.86,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.14,13.88,
SKIN TEST TUBERCULOSIS,6100231,CDM,300,RC,86580,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.34,36.88,
TUBERCULIN SKIN TEST,6100232,CDM,300,RC,86580,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.34,36.88,
H1N1 VACCINE,6100267,CDM,636,RC,90663,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
URINALYSIS,6100438,CDM,300,RC,81003,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,12,
PROTHROMBIN TIME,6300045,CDM,300,RC,85610,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.14,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.86,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.14,13.88,
URINALISYS,6300049,CDM,300,RC,81000,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,12,
URINE DIP,6300050,CDM,300,RC,81002,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.74,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.74,12,
CEFTRIAXONE PER 250 MG,6300138,CDM,636,RC,J0696,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
"VITAMIN B12 UP TO 1,000 MCG",6300156,CDM,636,RC,J3420,HCPCS,both,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,15,
ER CAST CUTTER PADDING 3,1400020,CDM,271,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
ER CAST CUTTER PADDING 4,1400021,CDM,271,RC,,,outpatient,,,11.5,8.63,,9.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.63,9.2,
ER CAST CUTTER PADDING 6,1400022,CDM,271,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
GLYCO HEMO SBC,6300178,CDM,301,RC,83036QW,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
FHC-URINALISYS,6900161,CDM,300,RC,81002,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.74,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.74,12,
TUBERCULIN SKIN TEST,6900171,CDM,300,RC,86580,HCPCS,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.34,36.88,
URINE DIP STICK/TAB RGNT WO MICRSCP,6900255,CDM,982,RC,81002QW,HCPCS,outpatient,,,15,11.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,9,9,
ZITHROMAX 100MG/5ML 15ML SUSP,3200961,CDM,637,RC,Q0144,HCPCS,outpatient,,,15.3,11.48,,12.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.16,12.24,
ZITHROMAX SUSP 200MG/5mL 22.5mL,3200966,CDM,637,RC,Q0144,HCPCS,outpatient,,,15.3,11.48,,12.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.16,12.24,
AMPICILLIN 500MG INJ,3200002,CDM,636,RC,J0290,HCPCS,both,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,15.5,
BENADRYL INJ 50MG (DIPHENHYDRAMINE),3200067,CDM,636,RC,J1200,HCPCS,both,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,15.5,
LANOXIN 0.5MG 2CC INJ,3200447,CDM,636,RC,J1160,HCPCS,both,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,15.5,
LASIX 20MG/2ML INJ,3200451,CDM,636,RC,J1940,HCPCS,both,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,15.5,
BENADRYL INJ 50MG (DIPHENHYDRAMINE),6100067,CDM,636,RC,J1200,HCPCS,both,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,15.5,
G6PD 2ND CPT,2800914,CDM,301,RC,85041,HCPCS,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,12.8,
CPT 82570 HEAVY METAL URINE,2801163,CDM,301,RC,82570,HCPCS,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,18.27,
CORDARONE 150MG IV  3 ML,3200170,CDM,636,RC,J0282,HCPCS,both,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,16,
DECADRON 4MG/1ML  INJ,3200210,CDM,636,RC,J1100,HCPCS,both,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,16,
CELESTONE PER 3MG,6900105,CDM,982,RC,J0702,HCPCS,outpatient,,,16,12,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.41,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.41,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,6.41,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,6.41,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.41,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6.41,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.26,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,6.41,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,8.97,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6.41,10.26,
DRAMAMIN PER 50 MG,6900111,CDM,982,RC,J1240,HCPCS,outpatient,,,16,12,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,14.38,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,12.59,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,14.38,
LIDOCAINE 1% 10MG/1ML 50mL,3200474,CDM,636,RC,J2001,HCPCS,both,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,16.5,
BLOOD TYPE-RH D,2800119,CDM,300,RC,86901,HCPCS,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.99,50.19,
VOLUME MEASUREMENT FOR TIMED COLLECTION,2800657,CDM,301,RC,81050,HCPCS,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.82,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.82,13.6,
IV CONNECTOR -10656,6200440,CDM,360,RC,99070,HCPCS,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
TEGADERM 8 X12,6200441,CDM,360,RC,99070,HCPCS,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
ALLERGEN SINGLE INJ THERAPY,6900064,CDM,982,RC,95115,HCPCS,outpatient,,,17,12.75,,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,14.38,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,12.59,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6.59,14.38,
K-WIRE 1.2MM,890138,CDM,278,RC,C1713,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,869.4,
K-WIRE 2.0,890203,CDM,278,RC,C1729,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
K-WIRE(390164),890226,CDM,278,RC,C1769,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
ALLERGEN ASPERGILLUS NIGER,2800038,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN AMERICAN COCKROACH,2800039,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN RAGWEED COMMON,2800040,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN LAMBS QUARTER WEED,2800041,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN PECAN TREE,2800043,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN COCONUT,2800044,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN GREEN PEAS,2800045,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN PECAN,2800046,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN RICE,2800047,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ER DERMABOND,1400058,CDM,272,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
ALLERGEN WHOLE EGG,2800049,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
TEST URINE UROBILINOGEN,2800597,CDM,301,RC,84578,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.15,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.23,14.4,
ALLERGEN ALTERNARIA ALTERNATA,2800721,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN AMERICAN ELM,2800722,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN ASPERGILLUS FUMIGATUS,2800723,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN BAHIA GRASS,2800724,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN BERMUDA GRASS,2800725,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN MAPLE/BOX ELDER,2800726,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN CAT HAIR,2800727,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN CLADOSPORIUM HERBARUM,2800728,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN DOG EPITHELIUM,2800731,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN ENGLISH PLANTAIN,2800732,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN JOHNSON GRASS,2800733,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN KENTUCKY BLUEGRASS,2800734,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN MESQUITE,2800735,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN MOUNTAIN CEDAR,2800736,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN MUCOR RACEMOSUS,2800737,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN NETTLE,2800738,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN PENICILLIUM,2800739,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN PIGWEED ROUGH,2800740,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN SWEET GUM,2800743,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN WHITE ASH,2800744,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN WHITE HICKORY,2800745,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN WHITE MULBERRY,2800746,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN WHITE OAK,2800747,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN LENSCALE,2800748,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN RYE GRASS,2800749,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN RAGWEED GIANT,2800750,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN HELMINTHOSPORIUM HALODES,2800751,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN LETTUCE,2800783,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN  RICE,2800784,CDM,300,RC,86003,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ANECTINE 20MG / 10ML,3200005,CDM,636,RC,J0330,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
BRETHINE 1MG/ML FOR RESP.,3200087,CDM,636,RC,J7681,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
CYANOCOBALAMIN 1000MCG/ML INJ   1 ML,3200199,CDM,636,RC,J3420,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
FLUPHENAZINE 2.5MG/ML 1ML INJ,3200324,CDM,636,RC,J2680,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
PARAFFIN BATH TO 1 OR > AREAS,5100539,CDM,420,RC,97018GP,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,70,
PARAFFIN BATH TO 1 OR > AREAS,5100623,CDM,430,RC,97018GO,HCPCS,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,70,
CYANOCOBALAMIN 1000MCG INJ,6100199,CDM,636,RC,J3420,HCPCS,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
LIDOCAINE 0.5% 5MG/1ML 50mL,3200473,CDM,636,RC,J2001,HCPCS,both,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,19,
ACETYLCYSTEINE 10% 4ML,3201052,CDM,636,RC,J7608,HCPCS,both,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,19,
BLOOD GLUCOSE (HEMOQUE),6300032,CDM,300,RC,82947,HCPCS,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,15.2,
"INFLUE VACC, QUAD, 6-35 MONTHS- IM",6900040,CDM,982,RC,90687,HCPCS,outpatient,,,19,14.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.44,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.44,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.44,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.44,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.44,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.44,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.7,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,10.44,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,14.62,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.44,16.7,
SULFATE  24 HR URINE,2801062,CDM,300,RC,84392,HCPCS,outpatient,,,19.5,14.63,,15.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.74,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,10.73,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.49,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.23,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.74,16.78,
VISTARIL 25MG INJ,3200922,CDM,636,RC,J3410,HCPCS,both,,,19.65,14.74,,15.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.91,19.65,
PULSE OX  CONTINUOUS,1400246,CDM,460,RC,94761,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,16,
PULSE OX  MULTIPLE DETERMINATIONS,1400247,CDM,460,RC,94761,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,16,
PORT FLUSH,1400289,CDM,450,RC,96523,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,84.95,
ASSAY OF BODY FLUID ACIDITY,2800093,CDM,301,RC,83986,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.79,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,16,
BILIRUBIN DIRECT,2800111,CDM,301,RC,82248,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.5,16,
BILIRUBIN TOTAL,2800112,CDM,301,RC,82247,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.5,16,
BILIRUBIN TOTAL,2800113,CDM,301,RC,82247,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.5,16,
COLLECTION VENOUS BLOOD,2800177,CDM,300,RC,36415,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,16,
TENS APPLICATION,2800594,CDM,430,RC,97032GO,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,70,
BILIRUBIN DIRECT SEND OUT,2801047,CDM,301,RC,82248,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.5,16,
VISTASEQ 13,2801113,CDM,301,RC,81479,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,164.05,
SFMC RPR REFLEX ON POSITIVE,2801123,CDM,307,RC,86592,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,16,
86003 MANUAL CHARGE,2801341,CDM,301,RC,86003,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN PAPER WASP,2801406,CDM,300,RC,86003,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ALLERGEN YELLOW JACKET,2801407,CDM,300,RC,86003,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,18.44,
ATROPINE 1MG SYRINGE,3200037,CDM,636,RC,J0461,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
HEPARIN 1000 U/1ML 10mL,3200363,CDM,636,RC,J1644,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
HUMULIN N 3ML VIAL,3200370,CDM,636,RC,J1815,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
HUMULIN R 3ML VIAL,3200371,CDM,636,RC,J1815,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
KCL 40MEQ INJ,3200428,CDM,636,RC,J3480,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NOVOLIN N 10ML VIAL,3200628,CDM,636,RC,J1815,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NOVOLIN R 10ML VIAL,3200629,CDM,636,RC,J1815,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
PEDIAPRED 5MG/5ML,3200644,CDM,637,RC,J7510,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SOLU CORTEF 100MG,3200792,CDM,636,RC,J1720,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
STADOL 2MG INJ,3200802,CDM,636,RC,J0595,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
SUBLIMAZE 0.5MG/5ML INJ,3200808,CDM,636,RC,J3010,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
TORADOL 15MG INJ,3200870,CDM,636,RC,J1885,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
DOBUTAMINE 250MG / D5W 250 ML,3201526,CDM,636,RC,J1250,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NSS 3% 500 ML,3202283,CDM,636,RC,J7131,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
"B-12 10,000 MCG/10ML ONE VIAL",3206600,CDM,636,RC,J3420,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NSS 250ML,3300075,CDM,258,RC,J7050,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NSS 500ML,3300076,CDM,636,RC,J7040,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NM NON-HEU TC 99M ADD ON/DOSE,4000204,CDM,343,RC,Q9969,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
PRE EMPLOYMT UDS- COLLECTION ONLY,6000100,CDM,521,RC,99211,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,134.33,
URINE PREG TEST SCC,6000180,CDM,300,RC,84703,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,26.51,
ADMIN NASAL VACCINE,6000199,CDM,250,RC,90473,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,99.71,
SPECIAL SERVICES (EXTENDED HRS),6000250,CDM,521,RC,99051,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
UNASYN PER 1.5 G,6000288,CDM,636,RC,J0295,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
STADOL 1MG /1ML INJ,6000291,CDM,636,RC,J0595,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
BENADRYL INJ UP TO 50 MG,6000298,CDM,636,RC,J1200,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
TORADOL 15 MG,6000302,CDM,636,RC,J1885,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
LASIX UP TO 20 MG INJ,6000303,CDM,636,RC,J1940,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NUBAIN PER 10 MG INJ,6000306,CDM,636,RC,J2300,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
PHENERGAN 50 MG INJ,6000307,CDM,636,RC,J2550,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
TESTOSTERONE UP TO 100 MG,6000345,CDM,636,RC,J3120,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
UNASYN PER 1.5 G,6100004,CDM,636,RC,J0295,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
BENADRYL INJ UP TO 50 MG,6100015,CDM,636,RC,J1200,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
TORADOL 15 MG,6100018,CDM,636,RC,J1885,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
LASIX 10MG/ML,6100019,CDM,636,RC,J1940,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NUBAIN PER 10 MG INJ,6100022,CDM,636,RC,J2300,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
PHENERGAN 50 MG INJ,6100023,CDM,636,RC,J2550,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
TESTOSTERONE UP TO 100 MG,6100025,CDM,636,RC,J3120,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
URINE PREG TEST,6100224,CDM,300,RC,84703,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,26.51,
COMPLETE BLOOD COUNT,6100227,CDM,300,RC,85025,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,27.45,
MONONUCLEOSIS TEST,6100229,CDM,300,RC,86308QW,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SPECIAL SERVICES (EXTENDED HRS),6100305,CDM,521,RC,99051,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
URINALYSIS MICRO ONLY NELHC,6100431,CDM,300,RC,8101591,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
STADOL 1MG /1ML INJ,6100457,CDM,636,RC,J0595,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
PRE EMPLOYMT UDS- COLLECTION ONLY,6100486,CDM,521,RC,99211,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,134.33,
DEVELOPMNTL SCRN W/SCORING INSTRUMENT,6100733,CDM,521,RC,96110,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,191.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,191.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,191.01,
CAREGIVER HLTH RISK ASSMT SCORE DOC STND,6100734,CDM,521,RC,96161,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,64.72,
MEDICATION LIST DOCUMENTED IN MED RECORD,6100735,CDM,521,RC,1159F,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
REVIEW OF MEDS BY MD; DOCD IN MED REC,6100736,CDM,521,RC,1160F,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
PAIN SEVERITY; PAIN IS PRESENT,6100737,CDM,521,RC,1125F,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
PAIN SEVERITY; PAIN IS NOT PRESENT,6100738,CDM,521,RC,1126F,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
FUNCTIONAL STATUS ASSESSED,6100739,CDM,521,RC,1170F,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
URINE PREG TEST,6300001,CDM,300,RC,84703,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,26.51,
INFLUENZA,6300012,CDM,510,RC,90659,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
ALLEGEN IMMUNOTHERAPY,6300030,CDM,972,RC,95115,HCPCS,outpatient,,,20,15,,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,14.38,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,8.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,12.59,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6.59,14.38,
COMPLETE BLOOD COUNT,6300033,CDM,300,RC,85025,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,27.45,
MONONUCLEOSIS TEST,6300043,CDM,300,RC,86308,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,18.27,
PREGNANCY TEST URINE,6300044,CDM,300,RC,81025,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.77,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,22.34,
BENADRYL INJ UP TO 50 MG,6300136,CDM,636,RC,J1200,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
LASIX UP TO 20 MG,6300147,CDM,636,RC,J1940,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
LIDOCAINE HC1 50 CC,6300148,CDM,636,RC,J2000,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NUBAIN PER 10 MG,6300150,CDM,636,RC,J2300,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
PHENERGAN UP TO 50 MG,6300151,CDM,636,RC,J2550,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
TESTOSTERONE UP TO 100 MG,6300153,CDM,636,RC,J3120,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
TORADOL PER 15 MG,6300154,CDM,636,RC,J1885,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
UNASYN PER 1.5 G,6300155,CDM,636,RC,J0295,HCPCS,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
FLU SHOT ADMINISTRATION MEDICARE,6300162,CDM,771,RC,G0008,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,62.61,
ALLERGY INJ THERAPY 2 OR MORE,6900065,CDM,982,RC,95117,HCPCS,outpatient,,,20,15,,,,,,other,Not separately reimbursable for physician setting,7.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,10.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,7.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,7.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,10.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,16.77,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,10.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,14.67,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,7.96,16.77,
URINE PREG TEST,6900164,CDM,982,RC,84703,HCPCS,outpatient,,,20,15,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.52,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.52,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,7.52,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,7.52,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.52,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,7.52,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.03,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,7.52,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.53,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,7.52,12.03,
COMPLETE BLOOD COUNT,6900167,CDM,300,RC,85025,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,27.45,
MONONUCLEOSIS TEST,6900169,CDM,300,RC,86308QW,HCPCS,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
OCCULT BLOOD #2,2800011,CDM,300,RC,8227291,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
OCCULT BLOOD #3,2800012,CDM,300,RC,8227291,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
ASSAY OF PROTEIN SERUM,2800097,CDM,301,RC,84155,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,16.8,
OCCULT BLOOD,2800455,CDM,301,RC,82272,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.11,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.34,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.11,16.8,
SED RATE,2800550,CDM,305,RC,85651,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,16.8,
SED RATE SEND OUT,2801424,CDM,305,RC,85651,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,16.8,
DRAMAMINE 50MG INJ,3200263,CDM,636,RC,J1240,HCPCS,both,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,21,
PROCHLORPERAZINE 10MG/NS 50 ML,3200708,CDM,636,RC,J0780,HCPCS,both,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,21,
OCCULT BLOOD #2 SCC,6000169,CDM,300,RC,82270,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,16.8,
RHYTHM STRIP,6000241,CDM,730,RC,93040,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,68.59,
RHYTHM STRIP,6100299,CDM,730,RC,93040,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,68.59,
OCCULT BLOOD #2 NELHC,6100432,CDM,300,RC,82270,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,16.8,
RHYTHM STRIP,6300159,CDM,730,RC,93040,HCPCS,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,68.59,
PT/INR,6900212,CDM,982,RC,85610,HCPCS,outpatient,,,21,15.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.29,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.29,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,4.29,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,4.29,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.29,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,4.29,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.86,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,4.29,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,6.01,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,4.29,12.6,
ADM FLU VACCINE  SCC,608008,CDM,771,RC,G0008,HCPCS,outpatient,,,21.3,15.98,,17.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.57,62.61,
IMMUNIZATION ADMIN. 1 VACCINE,6000197,CDM,771,RC,90471,HCPCS,outpatient,,,21.3,15.98,,17.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.57,99.71,
ADMIN OF HEPATITIS  VACCINE RHC,6000283,CDM,771,RC,G0010,HCPCS,outpatient,,,21.3,15.98,,17.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.57,62.61,
ADMIN OF HEPATITIS  VACCINE RHC,6100548,CDM,771,RC,G0010,HCPCS,outpatient,,,21.3,15.98,,17.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.57,62.61,
BUN QUANTITATIVE,2800122,CDM,301,RC,84520,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.97,17.6,
GLUCOSE OTHER FLUID,2800307,CDM,301,RC,82945,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
GLUCOSE TOLERANCE BEYOND 3 SPEC,2800308,CDM,301,RC,82952,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
GLUCOSE-FBS QUANTITATIVE,2800310,CDM,301,RC,82947,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
GLUCOSE CSF,2800774,CDM,301,RC,82945,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
BUN CREATININE W/ EGFR,2800915,CDM,301,RC,84520,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.97,17.6,
GLUCOSE REPEAT,2800980,CDM,301,RC,8294791,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
SFMC GLUCOSE CSF,2801208,CDM,301,RC,82945,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
SFMC GLUCOSE OTHER FLUID,2801209,CDM,301,RC,82945,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
APOLIPOPROTEIN B,2801308,CDM,301,RC,82172,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.74,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,54.72,
GLUCOSE SCC,6000172,CDM,301,RC,82947,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
GLUCOSE TOLERANCE BEYOND 3 SPEC SCC,6000175,CDM,301,RC,82952,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
STREP(PRECIPITIN) SCC,6000188,CDM,300,RC,86403,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.77,35.99,
STREP SCC,6000194,CDM,300,RC,87880QW,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
STREP(PRECIPITIN),6100230,CDM,300,RC,87880QW,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
GLUCOSE,6100414,CDM,301,RC,82947,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
GLUCOSE TOLERANCE BEYOND 3 SPEC,6100423,CDM,301,RC,82952,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,17.6,
STREP,6100437,CDM,300,RC,87880,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.26,42.35,
STREP(PRECIPITIN),6300047,CDM,300,RC,86403,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.77,35.99,
STREP,6300048,CDM,300,RC,87880,HCPCS,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.26,42.35,
DELESTROGEN 20 MG/ML,6900112,CDM,982,RC,J1380,HCPCS,outpatient,,,22,16.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.62,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.62,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.62,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.62,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.62,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.62,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.99,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,10.62,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,14.87,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.62,16.99,
STREP(PRECIPITIN),6900170,CDM,982,RC,86403,HCPCS,outpatient,,,22,16.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.54,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.54,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,11.54,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,11.54,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.54,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,11.54,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.46,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,11.54,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,16.16,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,11.54,18.46,
DEXTROSTIX  (BLOOD ACCUCHECK),2800239,CDM,301,RC,82962,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.64,18.4,
PROTEIN TOTAL (24 HR URINE),2800501,CDM,301,RC,84156,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,18.4,
PROTEIN TOTAL OTHER SOURCE,2800503,CDM,301,RC,84157,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,18.4,
PROTHROMBIN,2800507,CDM,305,RC,85610,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.14,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.86,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.14,18.4,
RETICULOCYTES LABCORP,2800537,CDM,305,RC,85045,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.99,18.4,
TOTAL PROTEIN,2800677,CDM,301,RC,84155,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,18.4,
CYSTIC FIBROSIS PANEL COMPONENT,2800689,CDM,305,RC,83912,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
PROTEIN TOTAL CEREBROSPINAL FLUID,2800778,CDM,301,RC,84157,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,18.4,
PROTHROMBIN REPEAT,2800981,CDM,305,RC,8561091,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
PORPHOBILINOGEN 24 HR URINE,2800998,CDM,301,RC,84110,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.22,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.22,18.4,
CLINIC ROOM,1400241,CDM,761,RC,,,outpatient,,,138,103.5,,110.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55.53,110.4,
HEMOCUE,2801048,CDM,301,RC,82947,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,18.4,
SFMC TOTAL PROTEIN,2801140,CDM,301,RC,84155,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,18.4,
RETICULOCYTES IN-HOUSE,2801142,CDM,305,RC,85045,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.99,18.4,
SFMC TOTAL PROTEIN,2801167,CDM,301,RC,84155,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,18.4,
SFMC PROTEIN TOTAL (24 HR URINE),2801199,CDM,301,RC,84156,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,18.4,
SFMC CSF PROTEIN,2801207,CDM,301,RC,84157,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,18.4,
SFMC PROTEIN TOTAL OTHER SOURCE,2801210,CDM,301,RC,84157,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,18.4,
NSS 1000ML BOLUS,3203424,CDM,636,RC,J7030,HCPCS,both,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,23,
D5LR 500ML,3300055,CDM,636,RC,J7120,HCPCS,both,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,23,
D5NS 500ML,3300057,CDM,636,RC,J7042,HCPCS,both,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,23,
D5W 1000ML,3300059,CDM,636,RC,J7070,HCPCS,both,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,23,
D5W 500ML,3300063,CDM,636,RC,J7060,HCPCS,both,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,23,
NSS 1000ML,3300072,CDM,636,RC,J7030,HCPCS,both,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,23,
IV-RINGERS LACTATED 500ML-10903,3300079,CDM,258,RC,J7120,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
DEXTROSTIX  (BLOOD ACCUCHECK) SCC,6000176,CDM,301,RC,82962,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.64,18.4,
PROTHROMBIN SCC,6000186,CDM,305,RC,85610,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.14,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.86,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.14,18.4,
ER MSO,1400259,CDM,450,RC,99281,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,64.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,110.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.03,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,64.76,189.27,
ADMINISTRATION OF VACCINE IMMUNIZATION,6000360,CDM,521,RC,90474,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
DEXTROSTIX  (BLOOD ACCUCHECK),6100420,CDM,301,RC,82962,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.64,18.4,
PROTHROMBIN,6100434,CDM,305,RC,85610QW,HCPCS,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
MUCOMYST 20% 4ML,3200576,CDM,636,RC,J7608,HCPCS,both,,,23.5,17.63,,18.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,23.5,
SFMC CULTURE-TISSUE,2800222,CDM,306,RC,87070,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,30.4,
FECAL LEUKOCYTES (WBC STOOL),2800277,CDM,306,RC,89055,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,19.2,
GRAM STAIN,2800312,CDM,306,RC,87205,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,19.2,
INDIA INK,2800378,CDM,306,RC,87210,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,19.2,
KOH MOUNT,2800393,CDM,306,RC,87210,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,19.2,
WET PREP,2800666,CDM,306,RC,87210,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,19.2,
SFMC CULTURE-MRSA SCREEN,2800863,CDM,306,RC,87081,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.31,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.31,23.4,
CYCLOSPORA SMEAR STOOL,2801046,CDM,302,RC,87206,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.69,19.2,
SFMC GRAM STAIN,2801183,CDM,306,RC,87205,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,19.2,
NEOSYNEPHRINE 1ML,3200597,CDM,636,RC,J2371,HCPCS,both,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,24,
INDIA INK,6100436,CDM,306,RC,87210,HCPCS,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,19.2,
INFLUENZA EACH ADDITIONAL DOSE,6900026,CDM,982,RC,90461,HCPCS,outpatient,,,24,18,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,14.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,9.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,9.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,9.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,9.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.65,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,9.75,15.6,
IMMUNIZATION ADMIN EACH ADDTL,6900028,CDM,982,RC,90472,HCPCS,outpatient,,,24,18,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,14.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.57,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,13.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.87,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.48,21.57,
ER EAR/PULSE OX FOR O2 SAT SINGLE,1400070,CDM,460,RC,94760,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,20,
ACETONE QUALITATIVE,2800021,CDM,301,RC,82009,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.25,20,
CHOLESTEROL TOTAL,2800160,CDM,301,RC,82465,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.17,20,
ROM MEASUREMENTS,2800543,CDM,430,RC,95851GO,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,70,
SERUM KETONES QUALITATIVE,2800554,CDM,301,RC,82009,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.25,20,
URIC ACID BLOOD,2800623,CDM,301,RC,84550,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.25,20,
PINWORM PREP,2800686,CDM,306,RC,87172,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,20,
IFE & PROTEIN ELECTROPHORESIS RANDOM UR,2800865,CDM,300,RC,84156,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,20,
NICOTINE METABOLITE URINE,2800891,CDM,301,RC,80307,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.75,169.05,
POTASSIUM RANDOM URINE,2800895,CDM,300,RC,84300,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,20,
Decalcify tissue,2800940,CDM,301,RC,88311,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,20,
NASH FIBROSURE,2800963,CDM,302,RC,82465,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.17,20,
PORPHOBILINOGEN RANDOM URINE,2801019,CDM,301,RC,84110,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.22,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.22,20,
PHENERGAN 50mg INJ,3200656,CDM,636,RC,J2550,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
TORADOL 30MG INJ,3200871,CDM,636,RC,J1885,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
ZANTAC 50MG INJ,3200949,CDM,636,RC,J2780,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
VENTOLIN HFA INHALER 60 dose,3202638,CDM,637,RC,J3535,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
XR CAD DIAGNOSTIC,4000031,CDM,401,RC,77051TC,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
XR CAD SCREENING,4000032,CDM,403,RC,77052TC,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
XR PORTABLE EQUIP SET UP,4000170,CDM,320,RC,Q0092,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
MM CAD-DIAGNOSTIC,4000174,CDM,401,RC,77051TC,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
MM CAD-SCREENING,4000175,CDM,403,RC,77052TC,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
PR XR ELBOW-2 VIEWS RT,4010050,CDM,972,RC,7307026RT,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,15,15,
PR XR FINGERS MIN 2 VIEW RT,4010054,CDM,972,RC,7314026RT,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,15,15,
PR XR ELBOW 2 VIEWS LT,4010144,CDM,972,RC,7307026LT,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,15,15,
PR XR FINGERS MIN 2 VIEW LT,4010146,CDM,972,RC,7314026LT,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,15,15,
MM CAD-SCREENING,4010175,CDM,403,RC,77052TC,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER VISTA BRITETIP 6FR GUIDING,5890040,CDM,278,RC,C1887,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CHOLESTEROL TOTAL SCC,6000170,CDM,301,RC,82465,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.17,20,
FLU SWAB - SCC,6000193,CDM,300,RC,87804QW,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
PULSE OXIMETRY,6000243,CDM,460,RC,94760,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,20,
DRAMAMIN PER 50 MG,6000299,CDM,636,RC,J1240,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
KENALOG PER 10 MG,6000310,CDM,636,RC,J3301,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
ARISTOCORT PER 5 MG,6000311,CDM,636,RC,J3302,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CELESTONE 6MG/1ML INJ,6000321,CDM,636,RC,J0702,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CLEOCIN 300MG/2ML,6000322,CDM,636,RC,S0077,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CLEOCIN 600MG/2ML,6000323,CDM,636,RC,S0077,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CLEOCIN 900 MG/2ML,6000324,CDM,636,RC,S0077,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
KENALOG 40MG/1ML,6000332,CDM,636,RC,J3301,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
TETRACAINE EYE DROPS,6000347,CDM,250,RC,J3490,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
DRAMAMIN PER 50 MG,6100016,CDM,636,RC,J1240,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
KENALOG 10MG/ML INJ 5ML VIAL,6100027,CDM,636,RC,J3301,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
TELEMETRY PER HOUR,1800001,CDM,230,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
ARISTOCORT PER 5 MG,6100028,CDM,636,RC,J3302,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
FLU SWAB - NELHC,6100235,CDM,300,RC,87804QW,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
H1N1 IMMUNIZATION ADMINISTRATION,6100256,CDM,256,RC,90470,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
THERAPEUTIC INJECTION ADM FEE,6100296,CDM,250,RC,90782,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
PULSE OXIMETRY,6100302,CDM,460,RC,94760,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,20,
SPLINT FOREARM,6100404,CDM,270,RC,A4570,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CHOLESTEROL TOTAL,6100413,CDM,301,RC,82465,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.17,20,
KENALOG 40MG,6100664,CDM,636,RC,J3301,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CLEOCIN 300MG/2ML,6100665,CDM,636,RC,S0077,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CLEOCIN 600MG/2ML,6100666,CDM,636,RC,S0077,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CLEOCIN 900MG/2ML,6100667,CDM,636,RC,S0077,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CELESTONE 6MG/1ML INJ,6100681,CDM,636,RC,J0702,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CL-KENALOG 40MG/1ML INJ,6200631,CDM,360,RC,J3301,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
INFLUENZA 6-35 MONTHS,6300013,CDM,972,RC,90657,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,15,15,
TETANUS ABSORBED YOUNDER THAN 7,6300023,CDM,510,RC,90702,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
ARISTOCORT PER 5 MG,6300135,CDM,636,RC,J3302,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
CELESTONE PER 3MG,6300139,CDM,636,RC,J0702,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
DEPRO MEDROL 80 MG,6300140,CDM,636,RC,J1040,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
KENALOG PER 10 MG,6300146,CDM,636,RC,J3301,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
LINCOCIN UP TO 300 MG,6300149,CDM,636,RC,J2010,HCPCS,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
FLU SWAB - SCHOOL BASED HEALTH CENTER,6300169,CDM,300,RC,87804,HCPCS,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.27,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.27,42.35,
SCREENING EXAM FOR DRUG TESTING,6300187,CDM,972,RC,80305,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.6,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.6,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,12.6,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,12.6,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.6,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,12.6,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.16,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,12.6,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,17.64,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,12.6,20.16,
DEPRESSION SCREENING NEGATIVE,6300190,CDM,972,RC,G8432,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,15,15,
KENALOG 40MG/ML INJ,6900184,CDM,982,RC,J3301,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.86,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,1.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,1.62,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.05,15,
FLU SWAB - WOMEN'S HEALTH CLINIC,6900207,CDM,982,RC,87804,HCPCS,outpatient,,,25,18.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,16.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,16.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,26.48,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,16.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,23.17,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,15,26.48,
TRICHROME STAIN,2800613,CDM,311,RC,88313,HCPCS,outpatient,,,25.5,19.13,,20.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.03,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.03,114.74,
AQUA MEPHYTON 1MG INJ,3200016,CDM,636,RC,J3430,HCPCS,both,,,25.5,19.13,,20.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.26,25.5,
HEPARIN 2U/ML  500 ML,3201270,CDM,636,RC,J1644,HCPCS,both,,,25.5,19.13,,20.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.26,25.5,
ASSAY OF THYROID(T3 OR T4),2800099,CDM,301,RC,84479,HCPCS,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.23,20.8,
CHLORIDE-BLOOD,2800157,CDM,301,RC,82435,HCPCS,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.29,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.29,20.8,
POTASSIUM-SERUM,2800483,CDM,301,RC,84132,HCPCS,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.38,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.14,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.38,20.8,
REMVL IMPCT CERUMEN IRRIGTN/LAVAGE UNILA,6100686,CDM,969,RC,69209,HCPCS,outpatient,,,26,19.5,,,,,,other,Not separately reimbursable for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,19.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.66,21.98,
FHC- RSV,87807,CDM,300,RC,87807,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.55,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.1,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.55,42.35,
GLUCOSE 2 HR PP,2800306,CDM,301,RC,82950,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,21.6,
IRON & TIBC,2800370,CDM,301,RC,83550,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.37,30.85,
PHOSPHORUS-SERUM,2800475,CDM,301,RC,84100,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,21.6,
POTASSIUM-URINE,2800484,CDM,301,RC,84133,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.36,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.36,21.6,
RBC COUNT (BODY FLUID),2800529,CDM,309,RC,89050,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.36,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.36,21.6,
ALBUMIN BODY FLUID,2800033,CDM,301,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
SODIUM SERUM,2800569,CDM,301,RC,84295,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.4,21.6,
SODIUM 24 HOUR URINE,2800570,CDM,301,RC,84300,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,21.6,
T-4 (THYROXINE) TOTAL,2800590,CDM,301,RC,84436,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.43,21.6,
WHIRLPOOL-LARGE,2800667,CDM,430,RC,97022GO,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,70,
WHIRLPOOL-SMALL,2800668,CDM,430,RC,97022GO,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,70,
SFMC SODIUM 24 HOUR URINE,2801240,CDM,301,RC,84300,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,21.6,
SFMC POTASSIUM-URINE,2801248,CDM,301,RC,84133,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.36,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.36,21.6,
SEND OUT PHOSPHORUS,2801340,CDM,301,RC,84100,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,21.6,
APRESOLINE 20MG/1ML INJ.,3200014,CDM,636,RC,J0360,HCPCS,both,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,27,
PR XR CHEST 1 VIEW,4010036,CDM,972,RC,7104526,HCPCS,outpatient,,,27,20.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,16.2,16.2,
PR XR CHEST 1 VIEW port,4010037,CDM,972,RC,7101026,HCPCS,outpatient,,,27,20.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,16.2,16.2,
PR XR CHEST 1 VIEW*,4011139,CDM,972,RC,7104526,HCPCS,outpatient,,,27,20.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,16.2,16.2,
COVER 6177 STERILE RF HEAD COVER,5890116,CDM,275,RC,C1722,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NEBULIZER,6000242,CDM,460,RC,94664,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,283.02,
NEBULIZER,6100301,CDM,460,RC,94664,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,283.02,
NEBULIZER,6300058,CDM,410,RC,94664,HCPCS,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,283.02,
SPECIAL SERVICES (EXTENDED HRS),6900070,CDM,982,RC,99051,HCPCS,outpatient,,,27,20.25,,,,,,other,Not separately reimbursable for physician setting,13.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,13.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,13.38,16.2,
DEPO-MEDROL 80 MG INJ,6900107,CDM,982,RC,J1040,HCPCS,outpatient,,,27,20.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.76,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.76,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.76,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,10.76,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,10.76,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.76,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,17.22,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,10.76,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,15.06,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,10.76,17.22,
RSV,6900208,CDM,982,RC,87807,HCPCS,outpatient,,,27,20.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.1,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.1,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,13.1,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,13.1,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.1,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.1,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.96,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,13.1,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,18.34,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.1,20.96,
MAGNESIUM  24 HR URINE,2801061,CDM,300,RC,83735,HCPCS,outpatient,,,27.5,20.63,,22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.13,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.35,23.65,
ROPIVACAINE .5% 150MG/30ML,3204270,CDM,636,RC,J2795,HCPCS,both,,,27.75,20.81,,22.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.17,27.75,
MAG SULATE/D5W 100ML (1GM/100ML),3201984,CDM,636,RC,J3475,HCPCS,both,,,27.82,20.87,,22.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.19,27.82,
AMINO ACIDS RANDOM URINE,2800057,CDM,300,RC,,,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.91,103.2,
BACTRIM 1 vial INJ  10 ml,3200059,CDM,636,RC,S0039,HCPCS,both,,,27.86,20.9,,22.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.21,27.86,
BB BLOOD TYPE-RH,3000007,CDM,300,RC,86901,HCPCS,outpatient,,,27.88,20.91,,22.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.99,50.19,
ALBUMIN SERUM,2800032,CDM,301,RC,82040,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.47,22.4,
CHLORIDE-SPINAL FLUID,2800158,CDM,301,RC,82438,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.5,22.4,
CHLORIDE-URINE,2800159,CDM,301,RC,82436,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,22.4,
CO 2,2800174,CDM,301,RC,82374,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.44,22.4,
SFMC IGA,2800293,CDM,301,RC,82784,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,32.83,
SFMC IGG,2800294,CDM,301,RC,82784,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,32.83,
SFMC IGM,2800295,CDM,301,RC,82784,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,32.83,
GLOMERULAR FILTRATION RATE,2800305,CDM,300,RC,82565,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.68,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.56,22.4,
PROTEIN TOTAL RANDOM URINE,2800502,CDM,301,RC,84156,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,22.4,
URIC ACID 24HR URINE,2800622,CDM,301,RC,84560,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.54,22.4,
IMMUNOGLOBULIN G SUB PART 2,2800777,CDM,301,RC,82787,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.01,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.03,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.01,22.4,
ALBUMIN BODY FLUID,2800988,CDM,301,RC,82042,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.89,22.4,
SFMC BB COOMBS DIRECT,2801152,CDM,300,RC,86880,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.39,84.95,
SFMC PROTEIN TOTAL RANDOM URINE,2801195,CDM,301,RC,84156,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,22.4,
SFMC CHLORIDE-URINE,2801271,CDM,301,RC,82436,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,22.4,
BB COOMBS DIRECT,3000016,CDM,300,RC,86880,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.39,84.95,
BB DAT CHARGE ONLY,3000024,CDM,300,RC,86880,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.39,84.95,
DILANTIN 250MG INJ,3200245,CDM,636,RC,J1165,HCPCS,both,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,28,
ANTI-GRANULOCYTIC,2800078,CDM,300,RC,,,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,261.6,
SOLU MEDROL 125MG,3200795,CDM,636,RC,J2930,HCPCS,both,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,28,
D5LR 1000ML,3300054,CDM,636,RC,J7121,HCPCS,both,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,28,
RINGERS LACTATED INJ 1000ML,3300080,CDM,258,RC,J7120,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
IV-RINGERS LACTATED L7500-10123,3300081,CDM,258,RC,J7120,HCPCS,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
BICILLIN INJECTION,6900103,CDM,982,RC,J0561,HCPCS,outpatient,,,28,21,,,,,,other,Not separately reimbursable for physician setting,20.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,20.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,20.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,20.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,20.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,20.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,20.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,32.26,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,20.16,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,28.22,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.8,32.26,
LINCOCIN UP TO 300 MG,6900118,CDM,982,RC,J2010,HCPCS,outpatient,,,28,21,,,,,,other,Not separately reimbursable for physician setting,9.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.04,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.04,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,11.04,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,11.04,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,9.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,9.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,11.04,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,11.04,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,17.66,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,11.04,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,15.46,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,9.99,17.66,
ALKALINE PHOSPHATASE,2800037,CDM,301,RC,84075,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,23.2,
SFMC BODY FLUID ALBUMIN,2800100,CDM,301,RC,82042,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.89,23.2,
CALCIUM TOTAL,2800131,CDM,301,RC,82310,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.58,23.2,
CREATININE-SERUM,2800195,CDM,301,RC,82565,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.68,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.56,23.2,
CRP,2800196,CDM,302,RC,86140,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,23.2,
PHOSPHORUS 24 HOUR URINE,2800474,CDM,301,RC,84105,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,23.2,
SGOT,2800557,CDM,301,RC,84450,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,23.2,
ASSAY OF BLOOD LIPOPROTEIN,2800092,CDM,301,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
C-REACTIVE PROTEIN HIGH SENSITIVITY,2800685,CDM,302,RC,86141,HCPCS,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.47,45.72,
HYDROMORPHONE 4MG INJ,3200381,CDM,636,RC,J1170,HCPCS,both,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,29,
INAPSINE 5MG INJ,3200397,CDM,636,RC,J1790,HCPCS,both,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,29,
TIGAN 200MG/2ML INJ,3200852,CDM,636,RC,J3250,HCPCS,both,,,29.5,22.13,,23.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.87,29.5,
AMIKACIN SULF. INJ. 500 MG/2ML,3201925,CDM,636,RC,J0278,HCPCS,both,,,29.6,22.2,,23.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.91,29.6,
IV-NSS KCL 20 1000ML,101326,CDM,270,RC,J2912,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
AFB SMEAR,2800030,CDM,306,RC,87206,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.69,24,
ALANINE AMINO (ALT)(SGPT),2800031,CDM,301,RC,84460,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.65,24,
SFMC CULTURE-GENITAL,2800224,CDM,306,RC,87070,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,30.4,
MANUAL MUSCLE TESTING LOW COMPLEXITY,2800420,CDM,430,RC,97161GO,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,70,
"ASXL1, FULL GENE SEQUENCE",2800451,CDM,310,RC,81175,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1508.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1508.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1508.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,338.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1082.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1014.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,1508.07,
SGPT,2800558,CDM,301,RC,84460,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.65,24,
BODY FLUID PROFILE,2800684,CDM,306,RC,87206,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.69,24,
IMMUNOGLUBULIN A,2800704,CDM,301,RC,82784,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,32.83,
IMMUNOGLOBULIN G,2800705,CDM,301,RC,82784,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,32.83,
IMMUNOGLOBULIN M,2800706,CDM,301,RC,82784,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,32.83,
SURGICAL PATH GROSS,2800929,CDM,301,RC,88300,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.52,42.69,
SFMC CYCLO/ISO ADD ON CPT,2801071,CDM,301,RC,87015,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.34,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.34,24,
CELESTONE PER CC (6MG),3200135,CDM,636,RC,J0702,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
HEPARIN 1000U/1ML INJ,3200361,CDM,636,RC,J1644,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
THORAZINE 25MG 1CC,3200848,CDM,636,RC,J3230,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
TORADOL 60MG/2ML  INJ,3200872,CDM,636,RC,J1885,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
D5K20 1000ML,3300050,CDM,636,RC,J7030,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
PR XR ABD-1 VIEW (KUB),4010025,CDM,972,RC,7400026,HCPCS,outpatient,,,30,22.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,18,18,
PR XR ANKLE 2 VIEWS RT,4010026,CDM,972,RC,7360026RT,HCPCS,outpatient,,,30,22.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,18,18,
PR XR ANKLE 2 VIEWS LT,4010140,CDM,972,RC,7360026LT,HCPCS,outpatient,,,30,22.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,18,18,
PR XR ABD-1 VIEW (KUB)*,4011143,CDM,972,RC,7401826,HCPCS,outpatient,,,30,22.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,18,18,
ALANINE AMINO (ALT)(SGPT) SCC,6000178,CDM,301,RC,84460,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.65,24,
"INFLUENZA TRIVT, SPLIT- 6-35 MONTHS",6000208,CDM,636,RC,90657,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
"INFLU VACC, HIGH DOSE",6000211,CDM,636,RC,90662,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,117.44,
"INFLU VACC, QUADRIVALENT-LIVE, NASAL",6000213,CDM,636,RC,90672,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,44.46,
"INFLU VACC, QUAD, PRSRV FREE 6-35MONTHS",6000216,CDM,636,RC,90685,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
"INFLU VACC, QUAD,  6MONTH >",6000217,CDM,636,RC,90686,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.18,35.76,
"INFLU VACC, QUAD, 6-35 MONTHS- IM",6000218,CDM,636,RC,90687,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.22,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.22,30,
Allergy single inj therapy,6000244,CDM,521,RC,95115,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,62.62,
SMOKING CESSATION >3-10MINS,6000279,CDM,521,RC,99406,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,43.85,
ROCEPHIN PER 500 MG INJ,6000343,CDM,636,RC,J0696,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
"INFLUENZA TRIVT, SPLIT- 6-35 MONTHS",6100264,CDM,636,RC,90657,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
ALANINE AMINO (ALT)(SGPT),6100412,CDM,301,RC,84460,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.65,24,
Allergy single inj therapy,6100472,CDM,521,RC,95115,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,62.62,
MD SRVC REQD FOR PMD,6100507,CDM,521,RC,G0372,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
"INFLU VACC, QUADRIVALENT-LIVE, NASAL",6100513,CDM,636,RC,90672,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,44.46,
"INFLU VACC, HIGH DOSE",6100516,CDM,636,RC,90662,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,117.44,
"INFLU VACC, QUAD, PRSRV FREE 6-35MONTHS",6100518,CDM,636,RC,90685,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
"INFLU VACC, QUAD, 6MONTH & UP",6100519,CDM,636,RC,90686,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.18,35.76,
"INFLU VACC, QUAD, 6-35 MONTHS- IM",6100520,CDM,636,RC,90687,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.22,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.22,30,
"XR CALCANEUS, MIN 2 VIEWS",6100533,CDM,320,RC,73650,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,129.44,
SMOKING CESSATION >3-10MINS,6100551,CDM,521,RC,99406,HCPCS,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,43.85,
ROCEPHIN 500 MG INJ,6100660,CDM,636,RC,J0696,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
DEXAMETHASONE 10MG/ML,6900191,CDM,982,RC,J1100,HCPCS,outpatient,,,30,22.5,,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,0.21,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,0.13,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,0.18,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,0.12,18,
PR XR ZYGOMATIC ARCHES <3 VIEWS,40010136,CDM,972,RC,7014026,HCPCS,outpatient,,,30,22.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,18,18,
WIRES GUIDERIGHT,90001905,CDM,278,RC,C1769,HCPCS,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
HEPATITIS B SURFACE AG,2800343,CDM,302,RC,87340,HCPCS,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,36.46,
SICKLE CELL,2800560,CDM,305,RC,85660,HCPCS,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.75,24.8,
URINALYSIS W/O MICROSCOPIC,2800624,CDM,307,RC,81003,HCPCS,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,24.8,
ALLERGEN PROFILE MOLD,2801013,CDM,302,RC,86003,HCPCS,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,24.8,
BB SICKLE CELL CHARGE PER UNIT,3000033,CDM,305,RC,85660,HCPCS,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.75,24.8,
PR CT BONE DENSITY,4310072,CDM,972,RC,7707826,HCPCS,outpatient,,,31,23.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,18.6,18.6,
MAXIPIME 2 GM VIAL,3201800,CDM,636,RC,J0692,HCPCS,both,,,31.25,23.44,,25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.58,31.25,
ALLERGEN SOYBEAN,2800048,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
LDL DIRECT SEND OUT,2800401,CDM,301,RC,83721,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.25,30.17,
ALLERGEN SWEET POTATO,2800528,CDM,302,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
RHEUMATOID AGGLUTININ QUANTITATIVE,2800539,CDM,302,RC,86431,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.83,25.6,
TRIGLYCERIDES,2800615,CDM,301,RC,84478,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,25.6,
VET RENAL PANEL(BUN CREAT PHOR),2800642,CDM,300,RC,86677,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,41.05,
ALLERGEN DERMATOPHAGOIDES FARINAE,2800729,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN DERMATOPHAGOIDES PTERONYSSIMUS,2800730,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN SHEEP SORREL / DOCK,2800741,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN STEMPHYLIUM BOTRYOSUM,2800742,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
CELL COUNT CSF,2800768,CDM,301,RC,89051,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,25.6,
CELL COUNT SEROUS FLUID,2800769,CDM,301,RC,89051,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,25.6,
CELL COUNT SYNOVIAL W/ CRYSTALS,2800770,CDM,301,RC,89051,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,25.6,
ALLERGEN CHOCOLATE / COCOA,2800785,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN WALNUT,2800786,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN SALMON,2800787,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CRAB MIX,2800788,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN SHRIMP,2800789,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CATFISH,2800790,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN TUNA FISH,2800791,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN MACKEREL,2800792,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN SPINACH,2800793,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PECAN FOOD,2800794,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN RED APPLE,2800795,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN BEEF,2800796,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CHICKEN,2800797,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PORK,2800798,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN EGG WHITE,2800799,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN EGG YOLK,2800800,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN COWS MILK,2800801,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN SOYBEAN,2800802,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN WHEAT,2800803,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN BANANA,2800804,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN MELON,2800805,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CELERY,2800806,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN STRAWBERRY,2800807,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN TOMATO,2800808,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN ORANGE,2800809,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN POTATO,2800810,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN ALMOND,2800811,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PEANUT,2800812,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CORN,2800813,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN BREWERS YEAST,2800814,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN STRING BEAN,2800815,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CARROT,2800816,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN BROCCOLI,2800817,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CABBAGE,2800818,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN GRAPE FRUIT,2800819,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CUCUMBER,2800820,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PEACH,2800821,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN WHITE GRAPE,2800822,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN LEMON,2800823,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PINEAPPLE,2800824,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PEAR,2800825,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN MUSTARD,2800826,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CINNAMON,2800827,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN ONION,2800828,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN BAKERS YEAST,2800829,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN LIME,2800830,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN TANGERINE,2800831,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN TIMOTHY GRASS,2800835,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN RAGWEED FALSE,2800836,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN FIRE ANT,2800839,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN MOSQUITO WHOLE BODY,2800841,CDM,302,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN LOBSTER,2800876,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CRAWFISH,2800877,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
STREPTOZYME,2800910,CDM,302,RC,86063,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.88,25.6,
MICROALBUMIN (24 HR URINE),2800977,CDM,301,RC,82043,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,25.6,
TRIGLYCERIDES BODY FLUID,2800986,CDM,301,RC,84478,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,25.6,
ALLERGEN LIVE OAK,2801039,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN BRAZIL NUT,2801073,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CASHEW,2801074,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN HAZELNUT/FILBERT,2801075,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN MACADAMIA,2801076,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PISTACHIO,2801077,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN NUT PROFILE,2801078,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
SFMC RHEUMATOID AGGLUTININ QUANTITATIVE,2801131,CDM,302,RC,86431,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.83,25.6,
HEP B SURFACE AB QUALITATIVE,2801170,CDM,302,RC,86706,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.37,37.92,
SFMC CELL COUNT CSF,2801205,CDM,301,RC,89051,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,25.6,
SFMC CELL COUNT SEROUS FLUID,2801264,CDM,301,RC,89051,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,25.6,
SFMC TRIGLYCERIDES BODY FLUID,2801282,CDM,301,RC,84478,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,25.6,
SFMC MICROALBUMIN (24 HR URINE),2801296,CDM,301,RC,82043,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,25.6,
ALLERGEN CLAM,2801317,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN CODFISH,2801318,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN MILK,2801319,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN SCALLOP,2801320,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN SESAME SEED,2801321,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN PROFILE FOOD,2801322,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN GLUTEN,2801323,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
ALLERGEN DEER,2801402,CDM,300,RC,86003,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,25.6,
GARAMYCIN 60MG PREMI,3200332,CDM,636,RC,J1580,HCPCS,both,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,32,
DOT DRUG SCREEN COLLECTION,2800245,CDM,300,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
GARAMYCIN 80MG/2ML (GENTAMICIN),3200333,CDM,636,RC,J1580,HCPCS,both,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,32,
RHYTHM STRIP PROFESSIONAL,5500012,CDM,985,RC,93042,HCPCS,outpatient,,,32,24,,,,,,other,Not separately reimbursable for physician setting,5.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,19.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,6.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,6.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,5.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,5.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,6.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,10.64,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,6.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,9.31,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,5.5,19.2,
TRIGLYCERIDES SCC,6000179,CDM,301,RC,84478,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,25.6,
LINCOCIN UP TO 300 MG/ML,6000336,CDM,636,RC,J2010,HCPCS,both,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,32,
LINCOCIN UP TO 300 MG/1ML,6100021,CDM,636,RC,J2010,HCPCS,both,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,32,
TRIGLYCERIDES,6100416,CDM,301,RC,84478,HCPCS,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,25.6,
LEVAQUIN 250 MG 50mL PREMIX,3201209,CDM,636,RC,J1956,HCPCS,both,,,32.25,24.19,,25.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.98,32.25,
DEPO-MEDROL 40MG 1C,3200226,CDM,636,RC,J1030,HCPCS,both,,,32.76,24.57,,26.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.18,32.76,
MICROALBUMIN  URINE,2800428,CDM,301,RC,82043,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,26.4,
RAPID MONO,2800432,CDM,302,RC,86308,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,26.4,
MONO QUALITATIVE SEND-OUT,2800433,CDM,300,RC,86308,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,26.4,
RPR ASSOCIATED TITER CHARGE,2800464,CDM,307,RC,86592,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,26.4,
VDRL CSF,2800637,CDM,302,RC,86592,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,26.4,
RPR QUALITATIVE,2800950,CDM,307,RC,86592,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,26.4,
CHOLINESTERASE RBC,2801036,CDM,301,RC,82482,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.9,27.15,
SFMC CYCLOSPORA ISOSPORA EXAM,2801045,CDM,302,RC,87207,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.99,26.4,
SFMC MICROALBUMIN  URINE,2801145,CDM,301,RC,82043,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,26.4,
SFMC VDRL CSF,2801206,CDM,302,RC,86592,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,26.4,
THORAZINE 50MG 2CC INJ,3200849,CDM,636,RC,J3230,HCPCS,both,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,33,
UNASYN 1.5GM,3200897,CDM,636,RC,J0295,HCPCS,both,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,33,
PR XR STERNOCLAVICULAR JT,4010163,CDM,972,RC,7113026,HCPCS,outpatient,,,33,24.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,19.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,19.8,19.8,
VASOPNEUMATIC DEV TO ONE OR> AREAS,5100536,CDM,420,RC,97016GP,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,70,
MONO SCC,6000187,CDM,302,RC,86308,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,26.4,
RSV - START CLINIC,6000190,CDM,300,RC,86756,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.94,45.51,
MONO,6100426,CDM,302,RC,86308,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,26.4,
RSV - NELHC,6100456,CDM,300,RC,86756,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.94,45.51,
VDRL,6300052,CDM,300,RC,86592,HCPCS,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,26.4,
ZOSYN 2.25GM INJ,3201043,CDM,636,RC,J2543,HCPCS,both,,,33.15,24.86,,26.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.34,33.15,
APTT,2800088,CDM,305,RC,85730,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,27.2,
DRUG CONFIRMATION,2800246,CDM,301,RC,80305,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.3,31.7,
LDH,2800400,CDM,301,RC,83615,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.06,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,27.2,
DRUG CONFIRMATION-PCP,2800691,CDM,301,RC,83992,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.31,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.7,51.91,
DRUG CONFIRMATION-BARBITURATES,2800692,CDM,301,RC,80345,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.12,27.2,
DRUG CONFIRMATION-AMPHETAMINES SINGLE,2800693,CDM,301,RC,80324,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
DRUG CONFIRMATION-BENZODIAZEPINE,2800694,CDM,301,RC,80346,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
DRUG CONFIRMATION-OPIATES,2800695,CDM,301,RC,80361,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
DRUG CONFIRMATION-THC,2800696,CDM,301,RC,80150,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,41.08,
DRUG CONFIRMATION-COCAINE,2800697,CDM,301,RC,80353,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
OXYCODONE CONFIRMATION,2800959,CDM,301,RC,82542,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.13,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.04,63.76,
TRICYCLIC ANTIDEPRESSANTS SCREEN URINE,2800968,CDM,301,RC,G0431,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
MEDROL DOSEPAK 4MG,3200537,CDM,637,RC,J7509,HCPCS,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
DIPTH AND TET <5 YRS,6000223,CDM,636,RC,90702,HCPCS,both,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,34,
DIPTH AND TET <5 YRS,6100275,CDM,636,RC,90702,HCPCS,both,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,34,
ANTI-MITOCHONDRIAL ANTIBODY,2800081,CDM,301,RC,83516,HCPCS,outpatient,,,34.5,25.88,,27.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18.98,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,27.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,40.73,
ER IPECAC ADMIN/OBS UNTIL STOMACH EMP,1400116,CDM,940,RC,99175,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
ACHR BLOCKING ANTIBODIES,2800024,CDM,300,RC,83519,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.33,29.44,
DEVELOPMENT COG SKILLS 15 MIN,2800238,CDM,430,RC,97129,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,70,
DRUG SCREEN RANDOM,2800247,CDM,300,RC,80305,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.3,31.7,
SENSORY INTEGRATION 15 MIN,2800552,CDM,430,RC,97533,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,58.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,87.75,
URINALYSIS W MICRO,2800676,CDM,300,RC,81001,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.58,28,
CREATININE 24 HR URINE,2800720,CDM,301,RC,82570,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,28,
CREATININE RANDOM URINE,2800780,CDM,301,RC,82570,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,28,
LDH OTHER FLUID,2800867,CDM,301,RC,83615,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.06,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,28,
CALCIUM RANDOM URINE,2800924,CDM,301,RC,82340,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.01,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.01,28,
SFMC LDH BODY FLUID,2801234,CDM,301,RC,83615,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.06,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,28,
CREATININE BODY FLUID,2801314,CDM,301,RC,82570,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,28,
"TISSUE TRANSGLUTAMINASE, IGA",2801443,CDM,302,RC,86376,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.27,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.27,51.38,
AMPICILLIN 1GM INJ,3200001,CDM,636,RC,J0290,HCPCS,both,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,35,
KENALOG 40MG/1ML INJ,3200433,CDM,636,RC,J3301,HCPCS,both,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,35,
SOLU CORTEF 250MG,3200793,CDM,636,RC,J1720,HCPCS,both,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,35,
PR XR ZYGOMATIC ARCHES <3 VIEWS,4001136,CDM,972,RC,7014026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR CLAVICLE COMPLETE RT,4010043,CDM,972,RC,7300026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR ELBOW COMPLETE 3 VIEW RT,4010049,CDM,972,RC,7308026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR FOOT-2 VIEWS RT,4010061,CDM,972,RC,7362026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR FOREARM 2 VIEWS RT,4010062,CDM,972,RC,7309026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR WHOLE BODY CHILD SINGLE VIEW,4010063,CDM,972,RC,7601026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR HAND 2 VIEWS RT,4010066,CDM,972,RC,7312026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR HEEL MIN 2 VIEWS RT,4010068,CDM,972,RC,7365026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR KNEE 2 VIEW RT,4010074,CDM,972,RC,7356026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR LOWER EXT INFANT MIN 2 VIEWS RT,4010079,CDM,972,RC,73592RT26,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR NASAL BONES COMP MIN 3 VIEWS,4010098,CDM,972,RC,7016026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR ORBITS COMP MIN 4 VIEWS,4010099,CDM,972,RC,7020026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR PELVIS 1 OR 2 VIEW,4010100,CDM,972,RC,7217026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SACRUM AND OR COCCYX MIN 2 VIEW,4010104,CDM,972,RC,7222026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SELLA TURCICA,4010108,CDM,972,RC,7024026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SHOULDER 1 VIEW RT,4010109,CDM,972,RC,7302026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SINUSES <3 VIEWS,4010112,CDM,972,RC,7021026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SINUSES COMP MIN 3 VIEWS,4010113,CDM,972,RC,7022026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SOFT TISSUE NECK,4010117,CDM,972,RC,7036026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SPINE SINGLE VIEW,4010118,CDM,972,RC,7202026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR TOE MIN 2 VIEWS RT,4010126,CDM,972,RC,7366026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR WRIST 2 VIEWS RT,4010134,CDM,972,RC,7310026RT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR ZYGOMATIC ARCHES 3<VIEWS,4010136,CDM,972,RC,7014026,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR CLAVICLE COMPLETE LT,4010142,CDM,972,RC,7300026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR ELBOW COMPLETE 3 VIEW LT,4010143,CDM,972,RC,7308026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR FOREARM 2 VIEWS LT,4010148,CDM,972,RC,7309026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR HAND 2 VIEWS LT,4010149,CDM,972,RC,7312026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR HEEL MIN 2 VIEWS LT,4010151,CDM,972,RC,7365026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR KNEE 2 VIEW LT,4010154,CDM,972,RC,7356026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR LOWER EXTRE INFANT MIN 2 VIEWS LT,4010157,CDM,972,RC,7359226LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR SHOULDER 1 VIEW LT,4010161,CDM,972,RC,7302026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR TOE MIN 2 VIEWS LT,4010166,CDM,972,RC,7366026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR WRIST 2 VIEWS LT,4010167,CDM,972,RC,7310026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR WRIST COMP MIN 3 VIEW LT,4010168,CDM,972,RC,7311026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PR XR FOOT-2 VIEWS LT,4010183,CDM,972,RC,7362026LT,HCPCS,outpatient,,,35,26.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21,21,
PUNCH BIOPSY ADDITIONAL,6000110,CDM,521,RC,11101,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
THERAPEUTIC INJECTION ADM FEE,6000247,CDM,250,RC,96372,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,99.71,
THUMB SPLINT,6100031,CDM,270,RC,L3999,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
PUNCH BIOPSY ADDITIONAL,6100052,CDM,521,RC,11101,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
HEMO INFLU,6100262,CDM,636,RC,90645,HCPCS,both,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,35,
"POLIO VACC, ORAL",6100279,CDM,636,RC,90712,HCPCS,both,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,35,
THERAPEUTIC INJECTION ADM FEE,6100295,CDM,250,RC,96372,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,99.71,
HEMO INFLU,6100560,CDM,636,RC,90647,HCPCS,both,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,35,
HEMO INFLU HIB 4 DOSE,6100561,CDM,636,RC,90648,HCPCS,both,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,35,
POLIO VACC ORAL,6300020,CDM,510,RC,90712,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
URINE FOR STD'S,6300051,CDM,300,RC,81003,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,28,
INTERACTIVE GROUP PSYCHOTHERAPY,6300099,CDM,521,RC,90857,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NURSE EVALUATION,6300108,CDM,521,RC,T1001,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
DRUG SCREEN MEDICAL,2800612,CDM,301,RC,80305QW,HCPCS,outpatient,,,35.5,26.63,,28.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.53,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.29,28.4,
DRUG SCREEN - SERUM EACH CLASS,2800985,CDM,300,RC,G043191,HCPCS,outpatient,,,35.5,26.63,,28.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.53,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.29,28.4,
LASIX 40MG INJ,3200453,CDM,636,RC,J1940,HCPCS,both,,,35.5,26.63,,28.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.29,35.5,
VERSED 2MG INJ,3200916,CDM,636,RC,J2250,HCPCS,both,,,35.75,26.81,,28.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.39,35.75,
ZITHROMAX SUSP 200MG/5ML 15ML,3200965,CDM,637,RC,Q0144,HCPCS,outpatient,,,35.85,26.89,,28.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.43,28.68,
AMYLASE,2800062,CDM,301,RC,82150,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.24,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.24,28.8,
DRUG SCREEN - URINE,2800249,CDM,301,RC,80320,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.45,28.8,
T UPTAKE,2800589,CDM,301,RC,84480,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,28.8,
URINE PREGNANCY,2800621,CDM,301,RC,81025,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.77,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,28.8,
THROMBIN TIME,2800719,CDM,306,RC,85670,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.88,28.8,
CPT 83655 HEAVY METAL PROFILE ADD,2801215,CDM,301,RC,83655,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.05,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.05,42.74,
HEP B CORE ANTIBODY IGM,2801412,CDM,302,RC,86705,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.88,41.54,
DOPAMINE 800 MG /D5W 250 ML,3204069,CDM,636,RC,J1265,HCPCS,both,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,36,
PR XR KNEE COMPLETE 4 OR MORE VIEWS RT,4011077,CDM,972,RC,7356426RT,HCPCS,outpatient,,,36,27,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,21.6,21.6,
NM TC99M MACROAGGREGATED ALBU PER 10 MIC,4400038,CDM,343,RC,A9540,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
TRACTION TO 1 > MORE AREAS,5100550,CDM,420,RC,97012GP,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,70,
TRACTION TO 1 > MORE AREAS,5100551,CDM,430,RC,97012GO,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,70,
EKG Interpretation and report ONLY,5500004,CDM,985,RC,93010,HCPCS,outpatient,,,36,27,,,,,,other,Not separately reimbursable for physician setting,6.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,7.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,7.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,6.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,6.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,7.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,7.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,12.67,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,7.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,6.22,21.6,
URINE PREGNANCY SCC,6000167,CDM,301,RC,81025,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.77,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,28.8,
URINE PREGNANCY,6100439,CDM,301,RC,81025QW,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
ADDL DEBRIDEMENT WOUND AREA<20CM,6200544,CDM,360,RC,97598,HCPCS,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,161.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,161.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,161.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,161.85,
CULTURE-AFB CONCENTRATION,2800755,CDM,306,RC,87015,HCPCS,outpatient,,,36.72,27.54,,29.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.34,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.34,29.38,
CPT 86671 CHARGE ONLY,2801387,CDM,302,RC,86671,HCPCS,outpatient,,,36.75,27.56,,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.21,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.12,43.29,
CPK TOTAL,2800192,CDM,301,RC,82550,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.41,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.76,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.25,29.6,
LITHIUM,2800412,CDM,301,RC,80178,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.3,29.6,
SODIUM BODY FLUID,2800567,CDM,300,RC,84302,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.86,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.43,29.6,
SODIUM RANDOM URINE,2800568,CDM,300,RC,84300,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,29.6,
SFMC CPT 82550 ASSOC CHG,2800911,CDM,301,RC,82550,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.41,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.76,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.25,29.6,
CBC W/ NO DIFF,2800935,CDM,305,RC,85027,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.23,29.6,
SFMC LITHIUM,2801156,CDM,301,RC,80178,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.3,29.6,
SFMC SODIUM RANDOM URINE,2801184,CDM,300,RC,84300,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,29.6,
SFMC CREATININE RANDOM URINE,2801339,CDM,300,RC,82570,HCPCS,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,29.6,
IRON,2800390,CDM,301,RC,83540,HCPCS,outpatient,,,37.5,28.13,,30,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.23,30,
SERUM OSMOLALITY,2800555,CDM,301,RC,83930,HCPCS,outpatient,,,37.5,28.13,,30,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.3,30,
SFMC SERUM OSMOLALITY,2801242,CDM,301,RC,83930,HCPCS,outpatient,,,37.5,28.13,,30,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.3,30,
LINCOCIN 300MG/ML,6000335,CDM,636,RC,J2010,HCPCS,both,,,37.5,28.13,,30,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.09,37.5,
LINCOCIN 1.5 MG 2 UNITS,6100079,CDM,636,RC,J2010,HCPCS,both,,,37.5,28.13,,30,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.09,37.5,
FLUCONAZOLE 100MG/50ML,3204073,CDM,636,RC,J1450,HCPCS,both,,,37.75,28.31,,30.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.19,37.75,
MAGNESIUM,2800417,CDM,301,RC,83735,HCPCS,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.35,30.4,
OSMOLALITY URINE,2800462,CDM,301,RC,83935,HCPCS,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.41,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.23,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.41,30.4,
SFMC OSMOLALITY URINE,2801243,CDM,301,RC,83935,HCPCS,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.41,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.23,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.41,30.4,
SEND OUT MAGNESIUM,2801409,CDM,301,RC,83735,HCPCS,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.35,30.4,
FLU ADMIN INITIAL THROUGH 18YRS W/COUNSE,6900025,CDM,982,RC,90460,HCPCS,outpatient,,,38,28.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.71,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,21.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,29.5,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.07,33.71,
"INFLU VACC, QUAD, PRSRV FREE 6 MONTH UP",6900039,CDM,982,RC,90686,HCPCS,outpatient,,,38,28.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.35,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.35,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,22.35,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,22.35,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.35,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,22.35,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,35.76,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,22.35,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,31.29,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,22.35,35.76,
SFMC HEPATITIS A IGM,2800333,CDM,302,RC,86709,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,39.76,
HIGH SENSITIVITY CRP,2800352,CDM,302,RC,86141,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.47,45.72,
LIPASE,2800409,CDM,301,RC,83690,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.44,31.2,
TULARENSIS EACH,2800620,CDM,302,RC,86000,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.49,31.2,
HEMOGLOBINOPATHY FRACTIONATION,2801014,CDM,305,RC,85660,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.51,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.75,31.2,
HEPATITIS A ANTIBODY TOTAL,2801376,CDM,302,RC,86708,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.19,41.08,
SFMC CPT 86651 CHARGE ONLY,2801383,CDM,302,RC,86651,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,46.58,
SFMC CPT 86652 CHARGE ONLY,2801384,CDM,302,RC,86652,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,46.58,
SFMC CPT 86653 CHARGE ONLY,2801385,CDM,302,RC,86653,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,46.58,
SFMC CPT 86654 CHARGE ONLY,2801386,CDM,302,RC,86654,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,46.58,
"OT ELECTRICAL STIMULATION, EACH 15 MINS",5100621,CDM,430,RC,97032GO,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,70,
"PT ELECTRICAL STIMULATION, EACH 15 MINS",5197032,CDM,420,RC,97032GP,HCPCS,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,70,
DEPO-MEDROL 80MG,3200227,CDM,636,RC,J1040,HCPCS,both,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,39.5,
ACETYLCHOLINE RECEPTOR BINDING ANTIBODY,2800022,CDM,300,RC,83519,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.33,32,
CULTURE-GC SCREEN,2800210,CDM,306,RC,87081,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.31,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.31,32,
UROBILINOGEN QUANTITATIVE,2800632,CDM,301,RC,84580,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.77,32,
CELL COUNT CRYSTALS,2800771,CDM,301,RC,89060,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.99,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.66,32,
GGT IN HOUSE,2800871,CDM,301,RC,82977,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.6,32,
CELL COUNT SYNOVIAL FLD W/O CRYSTALS,2800889,CDM,309,RC,89051,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,32,
DRUG CONFIRMATION-MDMA,2800989,CDM,301,RC,80150,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,41.08,
BETA HYDROXYBUTYRATE,2801012,CDM,300,RC,82010,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.08,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.08,32,
FACTOR VIII INHIBITOR PROFILE,2801063,CDM,302,RC,85732,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.23,32,
SFMC FACTOR VIII INHIBITOR PROFILE,2801283,CDM,302,RC,85732,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.23,32,
CLEOCIN/NS IVPB : 300MG/50ML PM,3201006,CDM,636,RC,J0736,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
Diazepam 10mg/2ml carpuject INJ,3201702,CDM,636,RC,J3360,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
PR XR- A/C JOINTS W WEIGHT ONLY,4010022,CDM,972,RC,7305026,HCPCS,outpatient,,,40,30,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,24,24,
PR XR CHEST SPECIAL VIEW EX.DECUB,4010041,CDM,972,RC,7103526,HCPCS,outpatient,,,40,30,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,24,24,
UNLISTED MODALITY- PT,5100639,CDM,420,RC,97039GP,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,70,
UNLISTED MODALITY- OT,5100640,CDM,430,RC,97039GO,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,70,
UNLISTED MODALITY- ST,5100641,CDM,440,RC,97039GN,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,60,
ULTRASND 1 OR >AREAS EACH 15MIN- OT,5100642,CDM,430,RC,97035GO,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,70,
"INFLUENZA, TRIVT, SPLIT  3 AND ABOVE",6000209,CDM,636,RC,90658,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
Allergy inj therapy (2 or more),6000245,CDM,521,RC,95117,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,62.62,
LASIX 40MG INJ,6000334,CDM,636,RC,J1940,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
STADOL 2 MG/1ML INJ,6000344,CDM,636,RC,J0595,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
TORADOL 30 MG,6000348,CDM,636,RC,J1885,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
FINGER XRAY,6100201,CDM,320,RC,73140,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,129.44,
"INFLUENZA, TRIVT, SPLIT  3 AND ABOVE",6100265,CDM,636,RC,90658,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
INFLUENZA,6100266,CDM,636,RC,90659,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
Allergy inj therapy (2 or more),6100473,CDM,521,RC,95117,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,62.62,
XR KNEE COMPLETE 4 OR MORE VIEWS,6100528,CDM,320,RC,73564,HCPCS,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,174.35,
INFLUENZA INITIAL DOSE,6100562,CDM,636,RC,90460,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
INFLUENZA EACH ADDITIONAL DOSE,6100563,CDM,636,RC,90461,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
STADOL 2MG/1ML INJ,6100662,CDM,636,RC,J0595,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
TORADOL 30 MG,6100669,CDM,636,RC,J1885,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
LASIX 40 MG INJ,6100679,CDM,636,RC,J1940,HCPCS,both,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,40,
GROUP PSYCHOTHERAPY,6300081,CDM,972,RC,90853,HCPCS,outpatient,,,40,30,,,,,,other,Not separately reimbursable for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,37.02,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,32.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.39,37.02,
INFLUENZA QUAD VACCINE ADULT,6900031,CDM,982,RC,90688,HCPCS,outpatient,,,40,30,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.88,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.88,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,20.88,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,20.88,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.88,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,20.88,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.41,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,20.88,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,29.23,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,20.88,33.41,
SMOKING CESSATION>3-10 MINUTES,6900095,CDM,982,RC,99406,HCPCS,outpatient,,,40,30,,,,,,other,Not separately reimbursable for physician setting,11.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,11.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,11.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,11.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,18.51,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,11.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,16.2,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,11.22,24,
VIRTUAL TELEMED CHECK IN,6900219,CDM,982,RC,G2012,HCPCS,outpatient,,,40,30,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,12.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,12.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,12.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,19.54,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,12.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,17.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,12.21,24,
24 HOUR BUN/CREATININE,2800018,CDM,301,RC,84540,HCPCS,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.78,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.78,32.4,
PROTEIN/CREATININE RATIO,2800505,CDM,301,RC,82570,HCPCS,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,32.4,
PROTEIN/CREATININE RATIO,2800506,CDM,301,RC,84156,HCPCS,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,32.4,
ALBUMIN/CREATININE RATIO,2801114,CDM,301,RC,82043,HCPCS,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,32.4,
SFMC PROTEIN/CREATININE RATIO RANDOM URI,2801196,CDM,301,RC,84156,HCPCS,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,32.4,
PROTEIN/CREATININE RATIO SCC,6000171,CDM,301,RC,82570,HCPCS,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,32.4,
PROTEIN/CREATININE RATIO,6100417,CDM,301,RC,82570,HCPCS,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,32.4,
ASO TITER,2800090,CDM,302,RC,86060,HCPCS,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.65,32.8,
ASSAY OF GGT,2800094,CDM,301,RC,82977,HCPCS,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.6,32.8,
CALCIUM  24 HR URINE,2800133,CDM,300,RC,82340,HCPCS,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.01,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.01,32.8,
D-DIMER SEND-OUT,2800234,CDM,302,RC,85379,HCPCS,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.09,35.94,
GGT SEND OUT,2800302,CDM,301,RC,82977,HCPCS,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.6,32.8,
D-DIMER QUANTITATIVE,2801079,CDM,305,RC,85379,HCPCS,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.09,35.94,
SFMC ASO TITER,2801141,CDM,302,RC,86060,HCPCS,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.65,32.8,
HEPATITIS B (AGES 11-19),6300009,CDM,972,RC,90743,HCPCS,outpatient,,,41,30.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,118.16,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,103.39,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,24.6,118.16,
CRYOGLOBULIN QUALITATIVE OR SEMI QUAL,2800198,CDM,301,RC,82595,HCPCS,outpatient,,,41.5,31.13,,33.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.83,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.23,33.2,
FECAL FATS QUALITATIVE,2800276,CDM,301,RC,82705,HCPCS,outpatient,,,41.5,31.13,,33.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,22.83,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.1,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.54,33.2,
TOBRAMYCIN 80MG,3200860,CDM,636,RC,J3260,HCPCS,both,,,41.5,31.13,,33.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.7,41.5,
CEFOXITIN 1GM,3200130,CDM,636,RC,J0694,HCPCS,both,,,41.55,31.16,,33.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.72,41.55,
VARICELLA IGG FOR IMMUNITY,2800634,CDM,302,RC,86787,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,39.6,
HEPATITIS C ANTIBODY SCREEN NO REFLEX,2800856,CDM,302,RC,86803,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.13,50.38,
PARATHYROID HORMONE RELATED PEPTIDE,2800890,CDM,301,RC,82397,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,33.6,
ZINC URINE,2801092,CDM,301,RC,84630,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.69,40.2,
SFMC VARICELLA TITER (FOR ACTIVE DISEASE,2801157,CDM,302,RC,86787,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,39.6,
SFMC MANUAL CHARGE,2801342,CDM,301,RC,83020,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,45.47,
PR MM MAMMOGRAM BX SPECIMEN RT,4010085,CDM,972,RC,7609826RT,HCPCS,outpatient,,,42,31.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,25.2,25.2,
PR MM BX SPECIMEN,4011158,CDM,972,RC,7609826,HCPCS,outpatient,,,42,31.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,25.2,25.2,
THERAPEUTIC PROCEDURE GROUP 2 OR > PTS,5100537,CDM,420,RC,97150GP,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,70,
THERAPEUTIC PROCEDURE GROUP 2 OR > PTS,5100620,CDM,430,RC,97150GO,HCPCS,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,70,
XR BONE AGE AP BOTH HANDS ONLY,4000029,CDM,320,RC,77072TC,HCPCS,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
FLU SHOT ADMINISTRATION MEDICARE,6900096,CDM,982,RC,G0008,HCPCS,outpatient,,,43,32.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,25.8,25.8,
ADMIN OF PNEUM VIRUS VACCINE,6900097,CDM,982,RC,G0009,HCPCS,outpatient,,,43,32.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,25.8,25.8,
ADMIN OF HEPATITIS VACCINE,6900098,CDM,982,RC,G0010,HCPCS,outpatient,,,43,32.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,25.8,25.8,
CBC,2800145,CDM,305,RC,85025,HCPCS,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,35.2,
CBC SCC,6000185,CDM,305,RC,85025,HCPCS,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,35.2,
Haemophilus influenzae B vacc Hib 3 dose,6000205,CDM,636,RC,90647,HCPCS,both,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,44,
CBC NELHC,6100419,CDM,305,RC,85025,HCPCS,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,35.2,
HIB OMP 3 DOSE,6100538,CDM,636,RC,90647,HCPCS,both,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,44,
"INFLU VACC, QUAD, PRSRV FREE 6-35 MONTHS",6900038,CDM,982,RC,90685,HCPCS,outpatient,,,44,33,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,26.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,26.4,26.4,
THIAMINE 200MG/2ML  INJ,3200846,CDM,636,RC,J3411,HCPCS,both,,,44.25,33.19,,35.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.81,44.25,
HCG-B QUALITATIVE,2800321,CDM,301,RC,84703,HCPCS,outpatient,,,44.5,33.38,,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.48,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,35.6,
HCG QUALITATIVE SEND OUT,2801432,CDM,301,RC,84703,HCPCS,outpatient,,,44.5,33.38,,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.48,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,35.6,
ADENOSINE 12MG/4ML,3207855,CDM,636,RC,J0153,HCPCS,both,,,44.5,33.38,,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.91,44.5,
HCG-B SCC,6000181,CDM,301,RC,84703,HCPCS,outpatient,,,44.5,33.38,,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.48,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,35.6,
HCG-B,6100418,CDM,301,RC,84703,HCPCS,outpatient,,,44.5,33.38,,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.48,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,35.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,35.6,
INTRO NEEDLE/CATH VEIN,1400236,CDM,450,RC,3600059,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
ANTI DNASE B CHARGE ONLY,2800077,CDM,302,RC,86215,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,46.78,
SFMC CHARGE ONLY CALCIUM 24 HR,2800132,CDM,301,RC,82340,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.01,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.01,36,
CULTURE-IDENT 1,2800211,CDM,306,RC,87077,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.04,36,
CULTURE-IDENT 2 OR MORE EACH,2800212,CDM,306,RC,8707791,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
CULTURE-URINE,2800223,CDM,306,RC,87086,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.03,36,
CBC W/AUTOMATED DIFF,2800673,CDM,305,RC,85025,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,36,
HEMAGRAM,2800674,CDM,305,RC,85025,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,36,
FREE LIGHT CHAINS BLOOD,2800961,CDM,302,RC,83883,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,36,
FREE KAPPA AND LAMBDA LIGHT CHAINS,2800962,CDM,302,RC,83883,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,36,
CBC REPEAT,2800979,CDM,305,RC,8502591,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
C DIFF TOXIN,2801064,CDM,300,RC,87324,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,42.35,
SFMC CBC SEND-OUT,2801088,CDM,305,RC,85025,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.88,36,
CULTURE-URINE COMPREHENSIVE,2801094,CDM,306,RC,87086,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.03,36,
SFMC CULTURE-URINE,2801117,CDM,306,RC,87086,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.03,36,
ADENOVIRUS STOOL,2801312,CDM,300,RC,87301,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,42.35,
ANTITHROMBIN III ANTIBODY,2801326,CDM,305,RC,85300,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.92,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.92,41.82,
SYPHILIS TP,2801362,CDM,305,RC,86780,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,36,
HEPARIN 25000 PREMIX,3200362,CDM,636,RC,J1644,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
KCL/NS IVPB PREMIX 20MEQ/100ML,3201085,CDM,636,RC,J3480,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
P50,5200022,CDM,301,RC,82820,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.34,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.67,36,
TETANUS (Indiv. >7yrs old),6000227,CDM,636,RC,90714,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
HEPB VACC PED/ADOL 3 DOSE IM,6000236,CDM,636,RC,90744,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
TETANUS UNDER 7 YRS OF AGE,6000346,CDM,636,RC,90702,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
XR CHEST,6100177,CDM,320,RC,71045,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.36,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,129.44,
REHAB VISIT LEVEL 1,6100252,CDM,521,RC,99231,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
"TETANUS, absorbed under 7 years old",6100276,CDM,636,RC,90702,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
TD (Indiv. >7yrs old),6100283,CDM,636,RC,90714,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
HEPB VACC PED/ADOL 3 DOSE IM,6100291,CDM,636,RC,90744,HCPCS,both,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,45,
EST PT CONSULT I,6100344,CDM,521,RC,99261,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
TELEHEALTH ORIGINATING SITE FEE,9000001,CDM,780,RC,Q3014GT,HCPCS,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
DIPRIVAN 1% 20ML,3200254,CDM,636,RC,J2704,HCPCS,both,,,45.5,34.13,,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.31,45.5,
HDL,2800324,CDM,301,RC,83718,HCPCS,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.09,36.8,
URINE BACTERIA CULTURE,2800627,CDM,306,RC,87088,HCPCS,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.13,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.04,36.8,
COPPER URINE,2801091,CDM,301,RC,82525,HCPCS,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.2,43.82,
HDL SCC,6000177,CDM,301,RC,83718,HCPCS,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.09,36.8,
HDL,6100415,CDM,301,RC,83718,HCPCS,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.09,36.8,
URINE DRUG SCREEN BY DIRECT OBSERVATION,6100558,CDM,300,RC,80305,HCPCS,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.3,36.8,
MALARIA SMEAR,2800418,CDM,306,RC,87207,HCPCS,outpatient,,,46.5,34.88,,37.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,25.58,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.99,37.2,
"INFLUENZA LIVE VACCINE, TRIVT-NASAL",6900032,CDM,982,RC,90660,HCPCS,outpatient,,,47,35.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,28.2,28.2,
MORPHINE 10MG,3200566,CDM,636,RC,J2270,HCPCS,both,,,47.5,35.63,,38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.11,47.5,
CULTURE-MAC SUSCEPTIBILITY BROTH OF AFB,2800214,CDM,306,RC,87186,HCPCS,outpatient,,,47.52,35.64,,38.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.14,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,38.02,
KWIRE OMEGA  2.8,890010,CDM,278,RC,C1769,HCPCS,both,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,48,
ER IV INFUSION EA ADD HR UP TO 8HR,1400117,CDM,260,RC,90766,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
CRYOFIBRINOGEN,2800197,CDM,301,RC,82585,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.07,38.4,
FIBRINOGEN,2800280,CDM,305,RC,85384,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.86,38.4,
FUNGAL SEROLOGY COCCIDIOIDES,2800288,CDM,302,RC,86635,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.73,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.73,40.5,
SFMC FIBRINOGEN,2801239,CDM,305,RC,85384,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.86,38.4,
SFMC SIROLIMUS LEVEL,2801364,CDM,301,RC,80195,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.86,40.89,
VENTOLIN HFA INHALER 200 dose,3200914,CDM,637,RC,J3535,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
IONTOPHORES1 OR > AREAS; EACH 15 MINS PT,5100538,CDM,420,RC,97033GP,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,70,
PERFORMANCE TEST; WRITTEN REPORT; 15MINS,5100557,CDM,420,RC,97750GP,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,70,
PERFORMANCE TEST; WRITTEN REPORT; 15MINS,5100558,CDM,430,RC,97750GO,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,70,
IONTOPHORE 1 OR > AREAS; EACH 15 MINS OT,5100622,CDM,430,RC,97033GO,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,70,
AEROSOL TREATMENT-SUBSEQUENT,5200012,CDM,410,RC,94664,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,283.02,
VENOUS GAS ONLY,5200041,CDM,943,RC,82800,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.5,38.4,
HH NEBULIZER TREATMENT-SUBSEQUENT,5200044,CDM,410,RC,9464076,HCPCS,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
DO NOT USE,40110077,CDM,972,RC,73564RT26,HCPCS,outpatient,,,48,36,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,28.8,28.8,
ROCEPHIN 250 MG INJ,3200760,CDM,636,RC,J0696,HCPCS,both,,,48.5,36.38,,38.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.52,48.5,
NCV SENSORY NERVE,5600023,CDM,922,RC,95904,HCPCS,outpatient,,,48.5,36.38,,38.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.52,38.8,
Influenza Vaccine,3201057,CDM,636,RC,90688,HCPCS,both,,,48.6,36.45,,38.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.41,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,38.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.44,48.6,
AMPICILLIN INJ PWD 2 GM,3203603,CDM,636,RC,J0290,HCPCS,both,,,48.84,36.63,,39.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.65,48.84,
AMYLASE BODY FLUID,2800063,CDM,301,RC,82150,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.24,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.24,39.2,
BRUCELLA IGG EIA,2800121,CDM,302,RC,86622,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.46,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.46,39.2,
SFMC CULTURE-CATH TIP,2800202,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-CERVIX,2800205,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-EAR,2800206,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-EYE,2800207,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-FLUID,2800208,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-JOINT,2800213,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-MISCELLANEOUS,2800215,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-NASOPHARYNG,2800216,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-SENSITIVITY 1,2800217,CDM,306,RC,87186,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,39.2,
CULTURE-SENSITIVITY 2 OR MORE EACH,2800218,CDM,306,RC,8718691,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
CULTURE-SPUTUM,2800219,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-UPPER RESPIRATORY,2800221,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
CULTURE-WOUND,2800225,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
IMMUNOGLOBULIN E,2800377,CDM,301,RC,82785,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.23,58.14,
CPT 83825 HEAVY METAL PROFILE ADD,2800421,CDM,301,RC,83825,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.26,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.39,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.13,57.43,
OCP (STOOL) <REPORTABLE>,2800458,CDM,306,RC,87177,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.45,39.2,
CULTURE-BORDETELLA PERTUSSIS,2800761,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
BRUCELLA ANTIBODY EACH ANTIBODY,2800844,CDM,302,RC,86622,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.46,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.46,39.2,
BRUCELLA ANTIBODY EACH ANTIBODY,2800845,CDM,302,RC,8662291,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
CBC W/ MANUAL DIFF,2800933,CDM,305,RC,85027,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.23,39.2,
OVA & PARASITES URINE,2801065,CDM,306,RC,87177,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.45,39.2,
SFMC CULTURE-WOUND,2801126,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
SFMC CULTURE-SPUTUM,2801136,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
PVA ONLY OCP (STOOL) <REPORTABLE>,2801147,CDM,306,RC,87209,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.99,53.55,
SFMC CULTURE-UPPER RESPIRATORY,2801168,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
SFMC CULTURE-FLUID (NOT CSF),2801179,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
SFMC AMYLASE BODY FLUID (NOT CSF),2801280,CDM,301,RC,82150,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.24,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.24,39.2,
SFMC CULTURE-EAR,2801306,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
SFMC CULTURE-CSF <REPORTABLE>,2801336,CDM,306,RC,87070,HCPCS,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,39.2,
WASHER ASNIS 3 FOR 4.0,890126,CDM,278,RC,C1713,HCPCS,both,,,49.46,37.1,,39.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.9,869.4,
OCCULT BLOOD EMESIS,2800330,CDM,301,RC,82271,HCPCS,outpatient,,,49.5,37.13,,39.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,27.23,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.66,39.6,
CLEOCIN IV 600MG,3200153,CDM,636,RC,J0736,HCPCS,both,,,49.5,37.13,,39.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.92,49.5,
CLINDAMYCIN 900MG/6mL INJ,3200156,CDM,636,RC,J0736,HCPCS,both,,,49.5,37.13,,39.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.92,49.5,
Zinacef 1.5gm Inj,3201104,CDM,636,RC,J0697,HCPCS,both,,,49.75,37.31,,39.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.02,49.75,
PR XR BILATERAL STANDING KNEES AP ONLY,401176,CDM,972,RC,7356526,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
TREATMENT ROOM,1400261,CDM,450,RC,99283,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,362.12,
TX-INJECTION IM/SUBCU,1600004,CDM,450,RC,96372,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,99.71,
TX-IV THERAPY EA ADDL HR UP TO 8HRS,1600009,CDM,260,RC,90761,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
CARNITINE QUANTITATIVE,2800140,CDM,301,RC,82379,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.43,59.56,
COMPATIBILITY TEST INCUBATION,2800179,CDM,300,RC,86921,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.79,232.4,
URINE-EOSINOPHIL COUNT,2800631,CDM,300,RC,87205,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,40,
BB COLD AGGLUTININ SCREEN,3000027,CDM,300,RC,86156,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.03,40,
LASIX 100mg INJ,3200450,CDM,636,RC,J1940,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
ZOFRAN INJ 4MG/2mL,3200971,CDM,636,RC,J2405,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
Cefepime 1gm/50ml Premixed,3202272,CDM,636,RC,J0703,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
MAXIPIME 2 GM PREMIXED,3202318,CDM,636,RC,J0703,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
DO NOT USE,4000119,CDM,972,RC,7113026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
GASTROGRAFIN 30 ML,4000197,CDM,636,RC,Q9963,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
DO NOT USE,4010023,CDM,972,RC,7402026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR ANKLE COMPLETE 3 VIEW  RT,4010028,CDM,972,RC,7361026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR CERVICAL SPINE 2 OR 3 VIEWS,4010034,CDM,972,RC,7204026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR CHEST 2 VIEWS,4010038,CDM,972,RC,7104626,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR CHEST WITH LORDOTIC,4010042,CDM,972,RC,7102126,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
DRUG COLLECTION URINE OR SERUM,2800628,CDM,300,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
PR XR FACIAL BONES COMP MIN 3 VIEWS,4010052,CDM,972,RC,7015026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR FEMUR 2 VIEW RT,4010053,CDM,972,RC,7355226RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR FLUORO CVA PLACEMENT,4010056,CDM,972,RC,7700126,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR FOOT COMP MIN 3 VIEWS RT,4010060,CDM,972,RC,7363026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR HIP BILATERAL MIN 2 VIEW,4010069,CDM,972,RC,7352226,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR HIP UNILATERAL MIN 2 VIEW RT,4010070,CDM,972,RC,7350226RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR HUMERUS MIN 2 VIEW RT,4010071,CDM,972,RC,7306026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR KNEE 3 VIEW RT,4010075,CDM,972,RC,7356226RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR LUMBAR SPINE 2 OR 3 VIEW,4010080,CDM,972,RC,7210026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
VET CBC,2800639,CDM,300,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
VET CHEM,2800640,CDM,300,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
VET PANEL(CBC SMA),2800641,CDM,300,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
PR XR MANDIBLE COMP MIN 4 VIEW,4010090,CDM,972,RC,7011026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
VET T4,2800643,CDM,300,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
PR XR MASTOIDS COMP MIN 3 VIEW,4010091,CDM,972,RC,7013026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR RIBS BILATERAL 3 VIEW,4010101,CDM,972,RC,7111026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR RIBS UNILATERAL 2 VIEW RT,4010102,CDM,972,RC,7110026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR SCANOGRAM BONE LENGTH,4010105,CDM,972,RC,7707326,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR SCAPULA COMPLETE RT,4010106,CDM,972,RC,7301026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR SCOLIOSIS STUDY,4010107,CDM,972,RC,7208326,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR SHOULDER COMPLETE MIN 2 VIEW RT,4010111,CDM,972,RC,7303026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR SKULL <4 VIEWS,4010114,CDM,972,RC,7025026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR STERNUM MIN 2 VIEW,4010120,CDM,972,RC,7112026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR THORACIC SPINE 2 VIEW,4010123,CDM,972,RC,7207026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR THORACIC SPINE 3 VIEW,4010124,CDM,972,RC,7207226,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR TIBIA/FIBULA 2 VIEW RT,4010125,CDM,972,RC,7359026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR URETHROGRAM-RETROGRADE,4010130,CDM,972,RC,7445026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR WRIST COMP MIN 3 VIEW RT,4010135,CDM,972,RC,7311026RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR ANKLE COMPLETE 3 VIEW  LT,4010141,CDM,972,RC,7361026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR FEMUR 2 VIEW LT,4010145,CDM,972,RC,7355226LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR FOOT COMP MIN 3 VIEWS LT,4010147,CDM,972,RC,7363026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR HAND MIN 3 VIEW LT,4010150,CDM,972,RC,7313026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR HIP UNILATERAL MIN 2 VIEW LT,4010152,CDM,972,RC,7350226LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR HUMERUS MIN 2 VIEW LT,4010153,CDM,972,RC,7306026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR KNEE 3 VIEW LT,4010155,CDM,972,RC,7356226LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR KNEE COMPLETE 4 OR MORE VIEWS LT,4010156,CDM,972,RC,7356426LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR RIBS UNILATERAL 2 VIEW LT,4010158,CDM,972,RC,7110026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR S.I JOINTS 3 OR MORE VIEWS BIL,4010159,CDM,972,RC,7220226,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR SCAPULA COMPLETE LT,4010160,CDM,972,RC,7301026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR SHOULDER COMPLETE MIN 2 VIEW LT,4010162,CDM,972,RC,7303026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR T M JOINTS BILATERAL,4010164,CDM,972,RC,7033026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR TIBIA/FIBULA 2 VIEW LT,4010165,CDM,972,RC,7359026LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR RIBS LT UNILATERAL W/1 VIEW CHEST,4010172,CDM,972,RC,7110126LT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR RIBS RT UNILATERAL W/1 VIEW CHEST,4010173,CDM,972,RC,7110126RT,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PRXR BILATERAL STANDING KNEES AP ONLY,4010176,CDM,972,RC,7356526,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
CBC MANUAL DIFF,2800675,CDM,305,RC,85007,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,1.9,8.84,
PR XR UPPER EXTRE INFANT MIN 2 VIEWS RT,4010181,CDM,972,RC,73092RT26,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR UPPER EXTRE INFANT MIN 2 VIEWS LT,4010182,CDM,972,RC,73092LT26,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR LUMBAR SPINE FLEXION & EXTENTION,4010201,CDM,972,RC,7212026,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR XR CHEST 2 VIEWS*,4011140,CDM,972,RC,7104626,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
STD PROFILE,2800683,CDM,306,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
PR XR CHEST WITH LORDOTIC*,4011141,CDM,972,RC,7104726,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR ABD 2 VIEW (FLAT AND ERECT)*,4011144,CDM,972,RC,7401926,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR US OTHER ST,4011151,CDM,972,RC,7699926,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
PR US ARTERIAL  EXT FOR ABI ONLY,4110007,CDM,972,RC,9392226,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30,30,
MRI MULTIHANCE 5ML,4200032,CDM,636,RC,A9577,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
PT ELEC STIMULATION 15 MIN,5100001,CDM,420,RC,G0283GP,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,70,
PT CONTRAST BATH,5100004,CDM,420,RC,97034GP,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,70,
PT ULTRASOUND 15 MIN,5100011,CDM,420,RC,97035GP,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,70,
AEROSOL TUBING,5200013,CDM,270,RC,94664,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,283.02,
INC SPIROMETER Device,5200047,CDM,410,RC,94640,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,283.02,
INC SPIROMETER TREATMENT,5200048,CDM,410,RC,94640,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,283.02,
CATHETERS 4 FR CORDIS,5800052,CDM,278,RC,C1725,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
EAR LAVAGE,6000162,CDM,521,RC,69210,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,116.34,
"INFLUENZA LIVE VACCINE, TRIVT-  NASAL",6000210,CDM,636,RC,90660,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
EST LEVEL 1 OV,6000257,CDM,521,RC,99211,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,134.33,
EST LEVEL 1 OV,6000258,CDM,521,RC,99211,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,134.33,
"CA SCREEN, PELVIC/BREAST",6000284,CDM,521,RC,G0101,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,112.1,
DEPRO MEDROL 40MG,6000294,CDM,636,RC,J1030,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
DEPO MEDROL 80 MG,6000295,CDM,636,RC,J1040,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
IMITREX 6 MG,6000309,CDM,636,RC,J3030,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
TELEMED 5-10 MIN AUDIO ONLY,6000355,CDM,521,RC,99441,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
DEPRO MEDROL 40MG,6100011,CDM,521,RC,J1030,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
DEPO MEDROL 80 MG,6100012,CDM,636,RC,J1040,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
CULTURE-ENVIRONMENTAL,2800710,CDM,306,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IMITREX 6 MG,6100024,CDM,636,RC,J3030,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
EAR LAVAGE,6100166,CDM,521,RC,69210,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,116.34,
XR NASAL BONES COMP MIN 3 VIEWS,6100169,CDM,320,RC,70160,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
PANORAMIC XR OF JAW,6100175,CDM,320,RC,70355,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
XR PELVIS 1 OR 2 VIEW,6100189,CDM,320,RC,72170,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,174.35,
CLAVICLE,6100191,CDM,320,RC,73000,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
XR SCAPULA,6100192,CDM,320,RC,7301026TC,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
XR ELBOW 2 VIEWS,6100195,CDM,320,RC,73070,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
FOREARM XRAY,6100197,CDM,320,RC,73090,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
XR KNEE 2 VIEW/PATELLA,6100205,CDM,320,RC,73560,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
XR ANKLE COMPLETE 3 VIEW,6100210,CDM,320,RC,73610,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
XR FOOT 2 VIEWS,6100211,CDM,320,RC,73620,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
XR HEEL,6100213,CDM,320,RC,73560TC,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
KUB XRAY,6100215,CDM,320,RC,74000,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
CL-POLIO INJECTION,6100280,CDM,636,RC,90713,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
EST LEVEL 1 OV,6100313,CDM,521,RC,99211,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,134.33,
EST LEVEL 1 OV,6100390,CDM,521,RC,99211,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,134.33,
"INFLUENZA LIVE VACCINE, TRIVT-  NASAL",6100405,CDM,636,RC,90660,HCPCS,both,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,50,
COLLECT BLOOD VENIPUNCTURE,6100435,CDM,450,RC,36415,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,40,
"CA SCREEN, PELVIC/BREAST",6100530,CDM,521,RC,G0101,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,112.1,
TELEMED 5-10 MIN AUDIO ONLY,6100718,CDM,521,RC,99441,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
REMOVAL STITCHES UNDER ANESTHESIA,6200409,CDM,360,RC,15850,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,475.51,
OFFICE VISIT-MINIMAL- PRO FEE,6210036,CDM,982,RC,99211,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.98,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,30,
CLAVICLE,6300054,CDM,320,RC,73000TC,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
ELBOW X-RAY,6300056,CDM,320,RC,73070TC,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
NASAL BONES XRAY,6300057,CDM,320,RC,70160TC,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
EAR LAVAGE,6300068,CDM,521,RC,69210,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,116.34,
EST LEVEL 1 OV,6300069,CDM,510,RC,99211,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.5,134.33,
SPIROMETRY TREATMENT,6300131,CDM,972,RC,94010,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,16.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,16.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,16.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,26.74,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,16.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,23.39,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.71,30,
NASAL BONES XRAY,6900130,CDM,320,RC,70160,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
FOREARM XRAY,6900146,CDM,320,RC,73090,HCPCS,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,129.44,
GARAMYCIN UP TO 80MG,6900213,CDM,982,RC,J1580,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.92,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.92,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.92,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.92,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2.92,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.92,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,4.67,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,2.92,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,4.09,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.92,30,
TELEMED 5-10 MIN AUDIO ONLY,6900218,CDM,982,RC,99441,HCPCS,outpatient,,,50,37.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,54.21,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,47.43,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30,54.21,
MEROPENEM 500MG VIAL,3203265,CDM,636,RC,J2185,HCPCS,both,,,50.4,37.8,,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.28,50.4,
THER/PROPH/DG IV INF ADD-ON,1400252,CDM,761,RC,90766,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
PARVOVIRUS B19 ANTIBODIES,2800471,CDM,302,RC,86747,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.51,53.07,
CRYPTOCOCCUS ANTIGEN CSF,2801031,CDM,306,RC,87899,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.03,42.35,
DIBUCAINE NUMBER,2801037,CDM,301,RC,82638,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.12,43.24,
AMIODARONE 900MG/18ML,3207454,CDM,636,RC,J0282,HCPCS,both,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,51,
LOW OSMOLAR CONTRAST 350-399 50ML,4000017,CDM,636,RC,Q9965,HCPCS,both,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,51,
PR NM CEREBRAL FLOW,4410010,CDM,972,RC,7861026,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,30.6,30.6,
INT COMP (AGE UNDER 1),6000265,CDM,521,RC,99381,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
INT COMP (AGE 01-4),6000266,CDM,521,RC,99382,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
INT COMP (AGE 05-11),6000267,CDM,521,RC,99383,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
INT COMP (AGE UNDER 1),6100366,CDM,521,RC,99381,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
INT COMP (AGE 01-4),6100367,CDM,521,RC,99382,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
INT COMP (AGE 05-11),6100368,CDM,521,RC,99383,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
PER COMP (AGE UNDER 1),6100373,CDM,521,RC,99391,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
PER COMP (AGE 01-4),6100374,CDM,521,RC,99392,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
PER COMP (AGE 05-11),6100375,CDM,521,RC,99393,HCPCS,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
INT COMP (AGE 01-4),6300094,CDM,972,RC,99382,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,81.6,
INT COMP (AGE 05-11),6300095,CDM,972,RC,99383,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,81.6,
INT COMP (AGE 12-17),6300096,CDM,972,RC,99384,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,86.25,
INT COMP (AGE 18-20),6300097,CDM,972,RC,99385,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,81.6,
INT COMP (AGE UNDER 1),6300098,CDM,972,RC,99381,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,81.6,
PER COMP (AGE 01-4),6300109,CDM,972,RC,99392,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,81.6,
PER COMP (AGE UNDER 1),6300113,CDM,972,RC,99391,HCPCS,outpatient,,,51,38.25,,,,,,other,Not separately reimbursable for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.6,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.6,81.6,
HIV,2800353,CDM,302,RC,86703,HCPCS,outpatient,,,51.5,38.63,,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.85,41.2,
T.PALLIDUM PARTICLE AGGN,2800587,CDM,302,RC,86780,HCPCS,outpatient,,,51.5,38.63,,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,41.2,
RAPID HIV,2800678,CDM,301,RC,86701,HCPCS,outpatient,,,51.5,38.63,,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.44,41.2,
HIV,6100427,CDM,302,RC,86701,HCPCS,outpatient,,,51.5,38.63,,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.44,41.2,
GUIDEWIRE HYDROPHILIC 150CM,90009963,CDM,278,RC,C1769,HCPCS,both,,,51.5,38.63,,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.72,51.5,
PROSTHETIC TRAINING 15 MIN,2800494,CDM,430,RC,97761GO,HCPCS,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,70,
OT WHEELCHAIR MANAGEMANT 15 MIN,5100012,CDM,430,RC,97542GO,HCPCS,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,70,
NEG PRESS WOUND THERAPY </=50 SQ CM,6100691,CDM,969,RC,97605,HCPCS,outpatient,,,52,39,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,31.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,24.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,24.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,24.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.51,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,24.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,33.7,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,24.07,38.51,
"INFLU VACC, QUADRIVALENT-LIVE, NASAL",6900035,CDM,982,RC,90672,HCPCS,outpatient,,,52,39,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,31.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,44.46,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,38.91,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,44.46,
SFMC TRIIODOTHYRONINE (T3),2801086,CDM,302,RC,84480,HCPCS,outpatient,,,52.5,39.38,,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,42,
METHAQUALONE SCREEN & CONFIRMATION,2801388,CDM,301,RC,80307,HCPCS,outpatient,,,52.5,39.38,,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.88,169.05,
PROPOXYPHENE SCREEN & CONFIRMATION,2801389,CDM,301,RC,80307,HCPCS,outpatient,,,52.5,39.38,,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,28.88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.88,169.05,
FORTAZ 1GM INJ,3200329,CDM,636,RC,J0713,HCPCS,both,,,52.75,39.56,,42.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.23,52.75,
CREATININE CLEARANCE,2800194,CDM,301,RC,82575,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.73,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.73,42.4,
CULTURE-STOOL YERSINIA ONLY,2800201,CDM,302,RC,87046,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,42.4,
CULTURE-STOOL <REPORTABLE>,2800220,CDM,302,RC,87045,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,42.4,
ORHOTIC TRAINING 15 MIN EACH,2800461,CDM,430,RC,97760GO,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,70,
SFMC IMMUNOGLOBULIN G SUBCLASSES (1-4),2800776,CDM,301,RC,82784,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,42.4,
STRONGYLOIDES ANTIBODY IGG,2800993,CDM,301,RC,86682,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.5,45.91,
SFMC CULTURE-STOOL <REPORTABLE>,2801144,CDM,302,RC,87045,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,42.4,
SFMC CREATININE CLEARANCE,2801191,CDM,301,RC,82575,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.73,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.73,42.4,
CULTURE-STOOL SHIGA TOXIN,2801349,CDM,302,RC,87046,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,42.4,
SFMC CULTURE-YERSINIA CULTURE STOOL,2801361,CDM,302,RC,87046,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,42.4,
SYNTHETIC SENTENCE ID TEST,5100630,CDM,440,RC,92576GN,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,60,
EAR PROTECTOR ATTEN MEASUREMENTS,5100632,CDM,440,RC,92596GN,HCPCS,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,60,
DTAP <7 YRS OLD,6900044,CDM,982,RC,90700,HCPCS,outpatient,,,53,39.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,31.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,31.8,31.8,
PARAINFLUENZA ANTIBODIES,2800468,CDM,301,RC,86710,HCPCS,outpatient,,,53.25,39.94,,42.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.29,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,42.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,42.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,47.86,
PROSTATIC ACID PHOS,2800493,CDM,301,RC,84066,HCPCS,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,43.2,
ST FILTERED SPEECH TEST,5100628,CDM,440,RC,92571GN,HCPCS,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,60,
ABG W/O PUNCTURE,5200099,CDM,301,RC,82803,HCPCS,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.1,43.2,
"PEAK EXPIRATORY FLOW RATE METER, HAND HE",5200111,CDM,272,RC,A4614,HCPCS,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
ADD-ON EACH UP TO 10 LESONS OR PART,6200047,CDM,360,RC,11201,HCPCS,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,309.77,
HEPATITIS B PED/ADOL 3 DOSE IM,6900058,CDM,982,RC,90744,HCPCS,outpatient,,,54,40.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,32.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,47.84,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,41.86,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,47.84,
HALDOL INJ 5MG,3200360,CDM,636,RC,J1630,HCPCS,both,,,54.5,40.88,,43.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.93,54.5,
HIB PEDIATRIC VACCINE,6100440,CDM,636,RC,90647,HCPCS,both,,,54.5,40.88,,43.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.93,54.5,
SCREW 4.5MM CORTICAL 36MM,890015,CDM,278,RC,C1713,HCPCS,both,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,869.4,
ALDOLASE,2800034,CDM,301,RC,82085,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.85,44,
GLYCOSYLATED HEMOGLOBIN A1C,2800311,CDM,301,RC,83036,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.85,44,
LUPUS ANTICOAGULANT,2800415,CDM,305,RC,85613,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.79,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.79,44,
GLYCOSYLATED HEMOGLOBIN SEND OUT,2800864,CDM,301,RC,83036,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.85,44,
SFMC LUPUS ANTICOAGULANT,2801214,CDM,305,RC,85613,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.79,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.79,44,
SFMC ALDOLASE,2801260,CDM,301,RC,82085,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.85,44,
SFMC MAYO LUPUS ANTICOAGULANT,2801331,CDM,305,RC,85613,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.79,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.79,44,
PR VOIDING CYSTOGRAM,4010198,CDM,972,RC,7445526,HCPCS,outpatient,,,55,41.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,33,33,
INTERMEDIAT JOINT OR BURSA,6000152,CDM,521,RC,20605,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,429.76,
XR FEMUR 1 VIEW,6100204,CDM,320,RC,73551,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,129.44,
INTERMEDIAT JOINT OR BURSA,6100454,CDM,521,RC,20605,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,429.76,
COCCYX XRAY,6300055,CDM,320,RC,72220TC,HCPCS,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,44,
CYSTATIN C,2801411,CDM,301,RC,82610,HCPCS,outpatient,,,55.5,41.63,,44.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.26,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.53,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,44.4,
SUTURE LASSO SD WIRE LOOP,890262,CDM,278,RC,A4649,HCPCS,both,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,56,
HELICOBACTOR PYLORI STOOL ANTIGEN,2800327,CDM,300,RC,87338,HCPCS,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,44.8,
LAP SCORE,2800399,CDM,305,RC,85540,HCPCS,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,44.8,
BB DONOR BLOOD ANTIGEN TYPE,3000005,CDM,300,RC,86902,HCPCS,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.2,479.01,
BB COMPATIBILITY TEST SPIN,3000015,CDM,300,RC,86920,HCPCS,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.8,232.4,
BB THAWING OF CRYOPRECIPITATE EA UNIT,3000018,CDM,300,RC,86931,HCPCS,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.06,479.01,
BB THAWING OF FFP EACH UNIT,3000019,CDM,300,RC,86927,HCPCS,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.1,232.39,
ATIVAN INJ 2MG,3200036,CDM,636,RC,J2060,HCPCS,both,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,56,
DIPTH AND TET ABSORBED  <7 YRS,6900045,CDM,982,RC,90702,HCPCS,outpatient,,,56,42,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,33.6,33.6,
NEGATIVE PRESSURE THERAPY <50CM,65197607,CDM,982,RC,97607,HCPCS,outpatient,,,56,42,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,34.64,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,21.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,30.31,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.65,34.64,
VALIUM 5mg/mL 10mL VIAL,3200901,CDM,636,RC,J3360,HCPCS,both,,,56.65,42.49,,45.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.8,56.65,
GC AB (N GONORRHOEAE),2800297,CDM,302,RC,86171,HCPCS,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5,45.6,
ROCKY MOUNT SPOTTED FEVER IgG,2800542,CDM,301,RC,86757,HCPCS,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,68.36,
ALLERGENS AREA VI,2800752,CDM,300,RC,82785,HCPCS,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.23,58.14,
SFMC CPT 82239 CHG ONLY,2801367,CDM,301,RC,82239,HCPCS,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.68,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.56,60.49,
CPT 82175 HEAVY METAL PROFILE ADD,2801414,CDM,301,RC,82175,HCPCS,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.48,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.48,66.99,
TD (INDIV.>7YRS OLD),6900049,CDM,982,RC,90714,HCPCS,outpatient,,,57,42.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.65,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,34.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.65,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,28.65,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,28.65,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.65,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,28.65,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.84,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,28.65,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,40.11,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,28.65,45.84,
CYSTOGRAFIN 18% HIGH IONIC PER ML,99999991,CDM,270,RC,Q9958,HCPCS,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
XOPENEX HFA INHALER,3200944,CDM,637,RC,J7612,HCPCS,outpatient,,,57.68,43.26,,46.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.21,46.14,
SCREW CORTICAL 4.5MM,890014,CDM,278,RC,C1713,HCPCS,both,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,869.4,
SCREW 4.5MM CORTICAL 38MM,890016,CDM,278,RC,C1713,HCPCS,both,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,869.4,
CULTURE-BLOOD,2800204,CDM,306,RC,87040,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,46.4,
FUNGUS STAIN,2800291,CDM,300,RC,87206,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.69,46.4,
RE-EVALUATION,2800531,CDM,434,RC,97004GO,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,70,
FRANCISELLA TULARENSIS ANTIBODIES,2800874,CDM,301,RC,86668,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.08,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.65,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.24,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.08,46.4,
FRANCISELLA TULARENSIS ANTIBODIES,2800875,CDM,301,RC,86668,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.08,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.16,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.65,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.24,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.08,46.4,
SFMC ADULT BLOOD CULTURE,2801118,CDM,306,RC,87040,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,46.4,
SFMC HEPATITIS B SURFACE AG,2801149,CDM,302,RC,87340,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,46.4,
SFMC PEDIATRIC BLOOD CULTURE,2801193,CDM,306,RC,87040,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,46.4,
Amikacin 1gm Inj,3201109,CDM,636,RC,J0278,HCPCS,both,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,58,
NM PH TC99M MERTIATIDE PER MCI UP TO 15,4400041,CDM,343,RC,A9562,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,46.4,
ER VISIT LEVEL I,6100347,CDM,521,RC,9928125,HCPCS,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,46.4,
LEVETIRACETAM 500MG/5ML INJECTION,3201484,CDM,636,RC,J1953,HCPCS,both,,,58.98,44.24,,47.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.73,58.98,
CIPRO 200MG IV/100ML,3200145,CDM,636,RC,J0744,HCPCS,both,,,59.5,44.63,,47.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.94,59.5,
VACCINE ADMIN-EACH ADDL VACCINE,1400101,CDM,260,RC,90472,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
ER IMMUNIZATION ADMIN EA ADD VACINE,1400102,CDM,450,RC,90472,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
ANTI-JO 1,2800087,CDM,302,RC,86235,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,48,
BASIC METABOLIC,2800109,CDM,301,RC,80048,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,48,
SFMC AMIODARONE,2800186,CDM,301,RC,80299,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,48.36,
CRYSTAL,2800200,CDM,309,RC,89060,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.99,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.66,48,
ESTRIOL,2800264,CDM,301,RC,82677,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,85.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.09,85.4,
HEP B SURFACE AB TITER,2800335,CDM,302,RC,86317,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,52.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,52.95,
LACTIC ACID LEVEL,2800395,CDM,301,RC,83605,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.78,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.78,48,
LIVER FUNCTION STUDY,2800413,CDM,301,RC,80076,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.08,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.08,48,
PROTEIN SERUM ELECTOPHORETIC FRAC&QUANT,2800500,CDM,301,RC,84165,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.37,48,
SFMC URINE PROTEIN ELECTROPHORESIS,2800504,CDM,301,RC,84166,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.91,62.96,
ROCKY MOUNTAIN SPOTTED FEVER IgM,2800846,CDM,302,RC,86757,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,68.36,
BETA 2 GLYCOPROTEIN 1 ANTIBODIES IGM,2800900,CDM,302,RC,86146,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,48,
BETA 2 GLYCOPROTEIN 1 ANTIBODIES IGG,2800901,CDM,302,RC,86146,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,48,
BASIC METABOLIC SEND OUT,2800913,CDM,301,RC,80048,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,48,
SFMC SERUM PROTEIN ELECTROPHORESIS,2801139,CDM,301,RC,84165,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.37,48,
SFMC LACTOFERRIN,2801173,CDM,306,RC,83630,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.85,48,
SFMC BETA 2 GLYCOPROTEIN 1 AB IGG,2801255,CDM,302,RC,86146,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,48,
SFMC MAYO SENSITIVITY,2801334,CDM,306,RC,87186,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,48,
SFMC MANUAL CHARGE,2801343,CDM,301,RC,83021,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,63.76,
SFMC AEROBIC SENSITIVITY MAYO,2801352,CDM,306,RC,87186,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,48,
AQUAMEPHYTON 10MG INJ,3200017,CDM,636,RC,J3430,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
LIDOCAINE 2GM/500ML PREMIX,3200476,CDM,636,RC,J2001,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
CLEOCIN/NS IVPB : 600MG/50ML PM,3201007,CDM,636,RC,J0736,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
PR ACUTE ABD SERIES W CXR-1/VIEW,4010024,CDM,972,RC,7402226,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,36,36,
PR XR GALL BLADDER/OR,4010064,CDM,972,RC,7430026,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,36,36,
PR XR GB IN OR ADDIT FILMS,4010065,CDM,972,RC,7430126,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,36,36,
PR XR HAND MIN 3 VIEW RT,4010067,CDM,972,RC,7313026RT,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,36,36,
PR ABD 3/VIEW *,4011145,CDM,972,RC,7402126,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,36,36,
PR MM Diag Dig Breast Tomosynt BIL,4011160,CDM,972,RC,7706226,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,36,36,
NM PH PERSANTINE 10MG,4400035,CDM,636,RC,J1245,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
NCV M/NERVE W/O F WA,5600022,CDM,922,RC,95900,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
INJ TRIGGER POINT 1 OR 2 MUSCLE(S) SCC,6000151,CDM,521,RC,20552,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,429.76,
DTAP <7 YEARS AGE,6000222,CDM,636,RC,90700,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
HIV/HBV,6000238,CDM,636,RC,90748,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
FLU SHOT ADMINISTRATION,6000281,CDM,771,RC,90471,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,99.71,
"BI CILLIIN INJECTION 100,000 UNITS",6000290,CDM,636,RC,J0561,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.24,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.16,60,
ROCEPHIN 1GM INJ,6000342,CDM,636,RC,J0696,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
TORADOL 60 MG,6000349,CDM,636,RC,J1885,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
TELEMED 11-20 MIN AUDIO ONLY,6000356,CDM,521,RC,99442,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
ADMIN OF INITIAL VACCINE 18YRS OR <,6100002,CDM,771,RC,90471,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,99.71,
BI CILLIIN INJECTION,6100007,CDM,636,RC,J0561,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.24,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.16,60,
XR RIBS UNILATERAL 2 VIEW,6100179,CDM,320,RC,71100,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,129.44,
XR THORACIC SPINE 2 VIEWS,6100186,CDM,320,RC,72070,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,174.35,
XR WRIST 2 VIEWS,6100198,CDM,320,RC,73110,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,129.44,
INP CONSULT REHAB 1,6100249,CDM,521,RC,99251,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
IMMUNIZATION ADMIN. 1 VACCINE,6100257,CDM,771,RC,90471,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,99.71,
DTAP,6100274,CDM,636,RC,90700,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
HIB/HBV,6100294,CDM,636,RC,90748,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
INJECTION ADMINISTRATION IM/SUBCUTANEOUS,6100303,CDM,521,RC,96372,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,99.71,
INT I/P CONSULT I,6100339,CDM,521,RC,99251,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
ADMIN NASAL VACCINE,6100458,CDM,250,RC,90473,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,99.71,
TREATMENT OF VAGINA,6100525,CDM,521,RC,57150,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,32.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,32.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,84.95,
INJ TRIGGER POINT 1 OR 2 MUSCLE(S),6100549,CDM,521,RC,20552,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,429.76,
ROCEPHIN 1 GM  INJ,6100661,CDM,636,RC,J0696,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
TORADOL 60 MG,6100670,CDM,636,RC,J1885,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
TELEMED 11-20 MIN AUDIO ONLY,6100719,CDM,521,RC,99442,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
IMMUNIZATION ADMIN 1 VACCINE,6300084,CDM,972,RC,90471,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.78,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,26.05,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,36,
BI-CILLIN 1.2,6300137,CDM,636,RC,J0540,HCPCS,both,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,60,
ADMIN OF IMMUNIZATION,6900027,CDM,982,RC,90471,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.78,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,18.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,26.05,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,18.61,36,
HIB PEDIATRIC VACCINE,6900029,CDM,982,RC,90647,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,36,36,
WRIST XRAY,6900148,CDM,320,RC,73110,HCPCS,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,129.44,
TELEMED 11-20 MIN AUDIO ONLY,6900215,CDM,982,RC,99442,HCPCS,outpatient,,,60,45,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,60,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,84,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36,96,
DELESTROGEN 20mg/mL 5mL E340B,3200214,CDM,636,RC,J1380,HCPCS,both,,,60.25,45.19,,48.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.24,60.25,
DELESTROGEN 20mg/mL,6100214,CDM,636,RC,J1380,HCPCS,both,,,60.25,45.19,,48.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.24,60.25,
SFMC HGB ELECTROPHORESIS,2800351,CDM,301,RC,83021,HCPCS,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,63.76,
HELICOBACTER PYLORI TEST,6900211,CDM,982,RC,86677,HCPCS,outpatient,,,61,45.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,16.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,16.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,26.96,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,16.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,23.59,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.85,36.6,
ALKALINE PHOS ISOENZYMES CHG ONLY,2801072,CDM,301,RC,84080,HCPCS,outpatient,,,61.5,46.13,,49.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,52.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.39,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,33.83,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.39,52.22,
CHOLINESTERASE SERUM,2800161,CDM,301,RC,82480,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.93,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.93,49.6,
ELECTROLYTES,2800262,CDM,301,RC,80051,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.5,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.21,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.5,49.6,
SFMC G6PD SCREEN,2800292,CDM,301,RC,82955,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.84,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.84,49.6,
PRE-ALBUMIN LEVEL,2800486,CDM,301,RC,84134,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.29,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.29,49.6,
T-3 FREE,2800588,CDM,301,RC,84481,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,49.6,
T-4 FREE,2800591,CDM,301,RC,84439,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.51,49.6,
PRE-ALBUMIN SENDOUT,2801001,CDM,301,RC,84134,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.29,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.29,49.6,
T-4 FREE SEND-OUT,2801051,CDM,301,RC,84439,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.02,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.51,49.6,
T-3 FREE SEND-OUT,2801052,CDM,301,RC,84481,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,49.6,
EST PT IP CONSULT,6100345,CDM,521,RC,99262,HCPCS,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
UNLISTED THER/PROP/IAG INJ/INF,6900068,CDM,982,RC,96379,HCPCS,outpatient,,,62,46.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,37.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,37.2,37.2,
ANA TITER,2800064,CDM,302,RC,86039,HCPCS,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.58,50.4,
C-PEPTIDE,2800190,CDM,301,RC,84681,HCPCS,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,73.47,
SFMC SMOOTH MUSCLE ANTIBODY,2800966,CDM,302,RC,86255,HCPCS,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,50.4,
SFMC ANA TITER,2801133,CDM,302,RC,86039,HCPCS,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.58,50.4,
GC/CHL SCREEN SCC,6000192,CDM,300,RC,87490,HCPCS,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.37,70.82,
GC/CHL SCREEN,6100234,CDM,300,RC,87490,HCPCS,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.37,70.82,
STREPTOCOCCUS GROUP A,6900024,CDM,982,RC,87880,HCPCS,outpatient,,,63,47.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.53,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,37.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.53,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,16.53,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,16.53,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.53,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.53,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,26.45,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,16.53,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,23.14,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.53,37.8,
ANTI-LA (SSB),2800080,CDM,302,RC,86235,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,51.2,
ANTI-RO(SSA)NUCLEAR ANTIGENS,2800084,CDM,302,RC,86235,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,51.2,
H PYLORI IGA IGG IGM,2800315,CDM,300,RC,86677,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,51.2,
H PYLORI IGG SEND OUT,2800316,CDM,302,RC,86677,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,51.2,
H PYLORI IGM,2800317,CDM,300,RC,86677,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,51.2,
ISOHEMAGGLUTININ TITER,2800391,CDM,300,RC,86940,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.38,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.03,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.38,51.2,
PHENOBARBITAL SERUM,2800472,CDM,301,RC,80184,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,51.2,
RETICULIN AB  IGG,2800536,CDM,301,RC,86255,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,51.2,
H PYLORI RAPID TEST,2800887,CDM,301,RC,86677,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,51.2,
SJOGRENS ANTIBODIES,2800939,CDM,302,RC,86235,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,51.2,
SFMC ANTI-SJOGREN (SSB),2801224,CDM,302,RC,86235,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,51.2,
SFMC ANTI SJOGREN SSA,2801225,CDM,302,RC,86235,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,51.2,
WATER CULTURE,2800960,CDM,306,RC,,,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
SFMC H PYLORI IGG SEND OUT,2801228,CDM,302,RC,86677,HCPCS,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,51.2,
LINCOMYCIN 600MG 2ML,6000305,CDM,636,RC,J2010,HCPCS,both,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,64,
LINCOMYCIN 600MG 12ML,6100406,CDM,636,RC,J2010,HCPCS,both,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,64,
INSULIN LEVEL TOTAL,2800385,CDM,301,RC,83525,HCPCS,outpatient,,,64.36,48.27,,51.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.71,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.14,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.71,51.49,
SFMC INSULIN LEVEL TOTAL,2801155,CDM,301,RC,83525,HCPCS,outpatient,,,64.36,48.27,,51.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.71,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.14,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,51.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.71,51.49,
OBSERVATION PER HOUR,300002,CDM,762,RC,G0378,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.84,100,,,case rate,100% Observation case rate,27.84,100,,,case rate,100% Observation case rate,27.84,100,,,case rate,100% Observation case rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,,,,other,Not separately reimbursable for outpatient setting,65,,,,other,Not separately reimbursable for outpatient setting,65,,,,other,Not separately reimbursable for outpatient setting,65,,,,other,Not separately reimbursable for outpatient setting,65,,,,other,Not separately reimbursable for outpatient setting,65,,,,other,Not separately reimbursable for outpatient setting,65,,,,other,Not separately reimbursable for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
ANTICARDIOLIPIN AB IGG,2800074,CDM,301,RC,86147,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,52,
CPK-MB,2800193,CDM,301,RC,82553,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.77,52,
PHYSICAL THERAPY RE-EVAL,2800476,CDM,420,RC,97164,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,120.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,120.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,120.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,66.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.75,120.2,
SFMC TISSUE TRANSGLUTAMINASE AB IGA,2800619,CDM,301,RC,83516,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,52,
ENDOMYSIAL ANTIBODY,2800779,CDM,302,RC,86255,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,52,
TISSUE TRANSGLUTAMINASE AB IGG,2800921,CDM,301,RC,83516,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,52,
GLIADIN ANTIBODY PROFILE,2800922,CDM,301,RC,83516,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,52,
GLIADIN ANTIBODY PROFILE,2800923,CDM,301,RC,83516,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,52,
ANTICARDIOLIPIN AB IGA,2800925,CDM,301,RC,86147,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,52,
ANTICARDIOLIPIN AB IGM,2800926,CDM,301,RC,86147,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,52,
VITAMIN B3,2801020,CDM,301,RC,84591,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.52,52,
SFMC ANTICARDIOLIPIN ANTIBODIES,2801218,CDM,301,RC,86147,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,52,
SFMC VITAMIN B3,2801273,CDM,301,RC,84591,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.52,52,
SFMC CARDIAC NO TROPONIN,2801369,CDM,301,RC,82553,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.77,52,
ZOVIRAX 500MG INJ,3200982,CDM,636,RC,J0133,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
CLINDAMYCIN 900MG PREMIX,3201633,CDM,636,RC,J0736,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
MAGNESIUM SULFATE 2 GM /50ML PM,3205100,CDM,636,RC,J3475,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
DO NOT USE,4000036,CDM,324,RC,71010TC,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
XR CHEST 1 VIEW*,4001139,CDM,324,RC,71045TC,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
HEPATITIS VACCINE <18 YRS 2 dose,6000203,CDM,636,RC,90633,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
TYPHOID,6000219,CDM,636,RC,90691,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
ELECTROCARDIOGRAM WO INTERPRETATION,6000240,CDM,730,RC,93005,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,84.95,
X-RAY MANDIBLE <4VIEWS,6100167,CDM,320,RC,70100,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,129.44,
LUMBAR SPINE AP & L,6100187,CDM,320,RC,72100,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,174.35,
REHAB VISIT,6100254,CDM,511,RC,99231,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
TYPHOID,6100271,CDM,636,RC,90691,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
ELECTROCARDIOGRAM WITHOUT INTERPRETATION,6100298,CDM,730,RC,93005,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,84.95,
HEPATITIS VACCINE <18 YRS,6100491,CDM,636,RC,90633,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
DEPRO-PROVERA 50 MG,6300141,CDM,636,RC,J1055,HCPCS,both,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,65,
ELECTROCARDIOGRAM,6300158,CDM,730,RC,93005,HCPCS,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,84.95,
DTAP (DAPTACEL) VACCINE,6100446,CDM,636,RC,90700,HCPCS,both,,,65.2,48.9,,52.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.24,65.2,
AMIKACIN LEVEL,2800055,CDM,301,RC,80150,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,52.8,
CARBAMAZ (TEGRETOL) TOTAL,2800138,CDM,301,RC,80156,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.28,52.8,
CULTURE-FUNGUS,2800209,CDM,306,RC,87101,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.85,52.8,
SFMC ANTI-PARIETAL CELL ANTIBODY,2800708,CDM,301,RC,83516,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,52.8,
IMMUNOGLUBULIN A SUBCLASS 1,2800775,CDM,301,RC,83883,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,52.8,
ANTICHROMATIN ANTIBODIES,2800852,CDM,302,RC,86235,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,52.8,
EXTRACTABLE NUCLEAR ANTIGEN,2800853,CDM,302,RC,8623591,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
ANTI-SMITH ANTIBODIES,2800854,CDM,302,RC,86235,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,52.8,
DRUG CONFIRMATION-TCA COMPONENT,2801008,CDM,301,RC,80337,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,20.84,20.84,
DRUG CONFIRMATION-TCA COMPONENT,2801009,CDM,301,RC,80338,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,20.84,20.84,
LEGIONELLA URINARY ANTIGEN,2800885,CDM,300,RC,87449,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,52.8,
ANTISCLERODERMA - 70 ANTIBODIES,2800936,CDM,302,RC,86235,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,52.8,
CANDIDA ANTIBODIES IGA IGG IGM,2800947,CDM,301,RC,86628,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.21,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,52.8,
CULTURE-FUNGUS W/ STAIN,2800965,CDM,306,RC,87101,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.85,52.8,
SFMC ANTI-SMITH ANTIBODIES,2801272,CDM,302,RC,86235,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,52.8,
SFMC CULTURE-CSF FUNGUS,2801337,CDM,306,RC,87102,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.2,52.8,
SFMC CULTURE- BLOOD FUNGUS,2801366,CDM,306,RC,87103,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.73,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.23,52.8,
INSULIN-LIKE GROWTH FACTOR 1,2801403,CDM,301,RC,84305,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,69.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.63,69.32,
TEGRETOL SEND-OUT,2801416,CDM,301,RC,80156,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.28,52.8,
BB BLOOD POOLING FEE,3000006,CDM,300,RC,86965,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.19,232.4,
UNASYN 3GM INJ,3200898,CDM,636,RC,J0295,HCPCS,both,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,66,
PROAIR HFA INH AER PWD 0.09MG/1ACT,3202611,CDM,637,RC,J3535,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
NM PH TC99M MEDRONATE / MCI (chg 1 unit),4400040,CDM,343,RC,A9503,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
ST TX SPEECH/VOICE/LANG GROUP 2 OR MORE,5100624,CDM,440,RC,92508GN,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,60,
NCV M/NERVE W/F WAVE,5600021,CDM,922,RC,95903,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
XR ORBITS COMP MIN 4 VIEWS,6100170,CDM,320,RC,70200TC,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
HIP XRAY,6100202,CDM,320,RC,73510,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
XR HIP UNILATERAL MIN 2 VIEW,6100539,CDM,320,RC,73502,HCPCS,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,129.44,
ANTI DNA SINGLE STRAND,2800870,CDM,302,RC,86225,HCPCS,outpatient,,,66.5,49.88,,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.58,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.87,53.2,
CHLAMYDIA AB IGG,2800152,CDM,302,RC,86631,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.91,53.6,
IMMUNOFIXATION (IFE),2800375,CDM,300,RC,86334,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,78.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.74,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.17,78.87,
LIPID SURVEY,2800410,CDM,301,RC,80061,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.69,53.6,
RENAL PANEL,2800532,CDM,301,RC,80069,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.34,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.34,53.6,
SALICYLATE SEND OUT,2800549,CDM,301,RC,G0480,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.21,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,183.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.85,183.08,
SACCHAROMYCES CEREVISIAE PROFILE,2800868,CDM,301,RC,86671,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.12,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.12,53.6,
SACCHAROMYCES IGA,2800869,CDM,301,RC,83520,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,53.6,
LIPID SENDOUT,2800997,CDM,301,RC,80061,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.69,53.6,
DO NOT USE,4000037,CDM,324,RC,71010TC,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.85,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
US ART DOP-UNILA LOWER EXT - LEFT,4100042,CDM,921,RC,93926TC,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
PR US ART DOP-UNILA LOWER EXT,4110005,CDM,972,RC,9392626,HCPCS,outpatient,,,67,50.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,40.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,40.2,40.2,
PR US ART DOP-UNILA LOWER EXT,4110042,CDM,972,RC,93926,HCPCS,outpatient,,,67,50.25,,,,,,other,Not separately reimbursable for physician setting,125.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,40.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,125.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,125.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,125.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,107.2,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,93.8,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,40.2,125.38,
LIPID SURVEY,6100430,CDM,301,RC,80061,HCPCS,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.69,53.6,
COMPLEMENT 4,2800182,CDM,302,RC,86160,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,54.4,
GIARDIA AG EIA,2800303,CDM,302,RC,87329,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,54.4,
HEP B CORE ANTIBODY TOTAL,2800334,CDM,302,RC,86704,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,54.4,
INF AGENT  EIA  NOT SPECIFIED,2800379,CDM,302,RC,8789991,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NMR LIPOPROFILE,2800446,CDM,300,RC,80061,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.69,54.4,
PROTEIN S ANTIGEN PLASMA,2800499,CDM,305,RC,85305,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.8,54.4,
SHIGA-LIKE TOXIN AG EIA,2800559,CDM,302,RC,87427,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,54.4,
SMOOTH MUSCLE ANTIBODY TITER,2800566,CDM,302,RC,86256,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,54.4,
STREP GROUP B (CSF),2800582,CDM,301,RC,87802,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.36,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.36,54.4,
HAEMOPHILUS INFLUENZA,2800764,CDM,301,RC,87899,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.03,54.4,
STREPTOCOCCUS PNEUMONIAE,2800765,CDM,301,RC,87899,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.03,54.4,
STREPTOCOCCUS GROUP B,2800766,CDM,301,RC,87802,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.36,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.36,54.4,
NEISSERIA MENINGITIDIS,2800767,CDM,301,RC,87899,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.03,54.4,
COMPLEMENT 2,2800842,CDM,302,RC,86160,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,54.4,
COMPLEMENT C1q QUANTITATIVE,2800843,CDM,302,RC,86160,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,54.4,
SFMC CRYPTOCOCCUS ANTIGEN,2801050,CDM,301,RC,87899,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.03,54.4,
SFMC COMPLEMENT 4,2801222,CDM,302,RC,86160,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,54.4,
SFMC HEP B CORE ANTIBODY TOTAL,2801233,CDM,302,RC,86704,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,54.4,
SFMC COMPLEMENT C1q QUANTITATIVE,2801302,CDM,302,RC,86160,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,54.4,
GARAMYCIN 80MG PREMI,3200334,CDM,636,RC,J1580,HCPCS,both,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,68,
RHYTHM STRIP,5500011,CDM,730,RC,93040,HCPCS,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,68.59,
Negative Pressure Therapy >50 sq cm,65197608,CDM,982,RC,97608,HCPCS,outpatient,,,68,51,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,40.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,25.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,25.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,25.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,40.16,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,25.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,35.14,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,25.1,40.8,
LINCOCIN 300MG INJ,3200484,CDM,636,RC,J2010,HCPCS,both,,,68.25,51.19,,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.46,68.25,
EMG/LIMB EXERCISE,5600018,CDM,922,RC,95875,HCPCS,outpatient,,,68.5,51.38,,54.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.56,214.92,
CARBON MONOXIDE QUANTITATIVE,2800139,CDM,301,RC,82375,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.16,55.2,
A-ANCA,2800712,CDM,301,RC,86256,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,55.2,
HISTOPLASMA ABS,2800917,CDM,302,RC,86698,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.68,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.89,55.2,
KIDNEY STONE URINE TEST,2801060,CDM,301,RC,82131,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.49,59.56,
SFMC CARBON MONOXIDE QUANTITATIVE,2801247,CDM,301,RC,82375,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.16,55.2,
SFMC TOTAL COMPLEMENT,2801258,CDM,302,RC,86162,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.16,67.35,
SFMC HISTOPLASMA ABS,2801292,CDM,302,RC,86698,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.68,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.89,55.2,
MM MAMMOGRAM BX SPECIMEN,4000085,CDM,320,RC,76098TC,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
PSA ULTRA SENSITIVE DIAGNOSTIC,28011188,CDM,301,RC,84153,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.19,64.95,
SFMC PSA ULTRA SENSITIVE DIAGNOSTIC,28011189,CDM,301,RC,84153,HCPCS,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.19,64.95,
GENTAMYCIN LEVEL,2800300,CDM,301,RC,80170,HCPCS,outpatient,,,69.5,52.13,,55.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.23,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.19,55.6,
INFED 50mg/ml 2mL INJ,3200405,CDM,636,RC,J1750,HCPCS,both,,,69.5,52.13,,55.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.41,69.5,
CERULOPLASMIN,2800150,CDM,301,RC,82390,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.37,56,
COPPER SERUM OR PLASMA,2800185,CDM,301,RC,82525,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.2,56,
FECAL UROBILNOGEN QUANTITATIVE,2800278,CDM,301,RC,84577,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.4,56,
FUNGAL SEROLOGY  HISTOPLASMOSIS,2800290,CDM,302,RC,86698,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.68,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.89,56,
HAPTOGLOBIN QUANTITATIVE,2800319,CDM,301,RC,83010,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.29,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.29,56,
SFMC CELL COUNT SYNOVIAL FLD W/ CRYSTALS,2800888,CDM,309,RC,89051,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,56,
TISSUE EXAM BY PATHOLOGIST,2800932,CDM,301,RC,88302,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,98.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.52,98.2,
SFMC COPPER SERUM OR PLASMA,2801257,CDM,301,RC,82525,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,43.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.2,56,
PR XR BONE AGE AP BOTH HANDS ONLY,4010029,CDM,972,RC,7707226,HCPCS,outpatient,,,70,52.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,42,42,
INJ SINGLE TENDON SHEATH/LIGAMENT SCC,6000150,CDM,521,RC,20550,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,429.76,
CRYOSURGERY,6100077,CDM,521,RC,17000,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,112.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,112.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,266.88,
XR SINUSES COMP MIN 3 VIEWS,6100172,CDM,320,RC,70220,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,129.44,
INJ SINGLE TENDON SHEATH/LIGAMENT,6100532,CDM,521,RC,20550,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,429.76,
NEG PRESSURE WOUND THERAPY < 50 SQ CM,6200433,CDM,360,RC,G0456,HCPCS,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
TETANUS & ACELLULAR PERTUSSIS,6900050,CDM,982,RC,90715,HCPCS,outpatient,,,70,52.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.67,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.67,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,38.67,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,38.67,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.67,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.67,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.87,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,38.67,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,54.14,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.67,61.87,
SFMC HAPTOGLOBIN,2800095,CDM,301,RC,83010,HCPCS,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.29,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.29,56.8,
HEAVY METAL URINE,2800325,CDM,301,RC,82300,HCPCS,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,81.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.82,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.82,81.72,
THYROTROPIN RECEPTOR ANTIBODY,2800605,CDM,300,RC,83520,HCPCS,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,56.8,
SFMC THYROTROPIN RECEPTOR ANTIBODY,2801300,CDM,300,RC,83520,HCPCS,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,56.8,
SELF CARE TRAINING; EACH 15 MINS,5100552,CDM,420,RC,97535GP,HCPCS,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,70,
IPOL (POLIO) VACCINE,6900048,CDM,982,RC,90713,HCPCS,outpatient,,,71,53.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,42.6,42.6,
VANCOMYCIN 1 GM/200ML PREMIXED,3207058,CDM,636,RC,J3372,HCPCS,both,,,71.05,53.29,,56.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.59,71.05,
ADM HEPATITIS B VACCINE,1400001,CDM,771,RC,G0010,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,62.61,
GLUCOSE TOLERANCE FIRST 3 SPEC,2800309,CDM,301,RC,82951,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.6,
HOT/COLD PACKS,2800361,CDM,270,RC,A9273,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
IL-28B (INTERLEUKIN 28B),2800372,CDM,306,RC,81400,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.98,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,83.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.96,100,,,fee schedule,100% UHC fee schedule for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,63.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,136.43,
LACTOSE TOLERANCE,2800396,CDM,301,RC,82951,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.6,
LIDOCAINE LEVEL,2800408,CDM,301,RC,80176,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.34,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.69,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.69,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.69,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.03,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.34,57.6,
"ASPA GENE ANALYSIS, COMMON VARIANTS",2800450,CDM,310,RC,81200,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,100.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,100.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,61.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,47.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.62,100.79,
NUC MOLECULAR DIAG-INTERP & REPORT,2800453,CDM,306,RC,83912,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NUC MOLECULAR DIAG-ISO EXTRACTION,2800454,CDM,306,RC,83890,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
ST.LOUIS ENCEPH AB IGM,2800571,CDM,300,RC,86653,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,57.6,
TRANSFERRIN,2800611,CDM,301,RC,84466,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.38,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.41,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.14,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.38,57.6,
CPT EXTRA CHARGE,2800756,CDM,301,RC,86256,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,57.6,
pANCA,2800757,CDM,301,RC,86256,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,57.6,
ANTIMYELOPEROXIDASE (MPO) ANTIBODIES,2800758,CDM,301,RC,83520,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,57.6,
ANTIPROTEINASE 3 (PR3) ANTIBODIES,2800759,CDM,301,RC,83520,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,57.6,
ANCA PROFILE,2800760,CDM,301,RC,86037,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,57.6,
ALPHA SUBUNIT FREE,2800967,CDM,306,RC,83520,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,57.6,
SFMC TRANSFERRIN,2801146,CDM,301,RC,84466,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.38,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.41,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.14,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.38,57.6,
SFMC ISLET CELL ANTIBODY SCREEN,2801365,CDM,302,RC,86341,HCPCS,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,69.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.78,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,30.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,23.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.78,69.89,
ACAPELLA DH W/MOUTHPIECE GREEN,90006259,CDM,270,RC,94664,HCPCS,outpatient,,,72.2,54.15,,57.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.05,283.02,
GTT 1 HOUR,2800013,CDM,300,RC,82951,HCPCS,outpatient,,,72.48,54.36,,57.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.86,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.98,
GTT 2 HOUR,2800014,CDM,300,RC,82951,HCPCS,outpatient,,,72.48,54.36,,57.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.86,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.98,
GTT 3 HOUR,2800015,CDM,300,RC,82951,HCPCS,outpatient,,,72.48,54.36,,57.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.86,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.98,
GTT 4 HOUR,2800016,CDM,300,RC,82951,HCPCS,outpatient,,,72.48,54.36,,57.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.86,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.98,
GTT 5 HOUR,2800017,CDM,300,RC,82951,HCPCS,outpatient,,,72.48,54.36,,57.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.86,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.98,
GTT 1 HOUR NELHC,6100422,CDM,300,RC,82951,HCPCS,outpatient,,,72.48,54.36,,57.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.86,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,57.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,57.98,
ANTI TETANUS ANTIBODY,2800072,CDM,302,RC,86774,HCPCS,outpatient,,,72.5,54.38,,58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,39.88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.4,58,
HEP A VACCINE,6100441,CDM,636,RC,90632,HCPCS,both,,,72.6,54.45,,58.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.21,72.6,
COXSOCKIE VIRUS AB,2800189,CDM,300,RC,86658,HCPCS,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.51,58.4,
FUNGAL SEROLOGY BLASTOMYCES,2800287,CDM,302,RC,86612,HCPCS,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.45,58.4,
PRE-PNEUMOCEAL AB TITER,2800488,CDM,302,RC,86609,HCPCS,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,58.4,
JOINT INJECTION,6300101,CDM,521,RC,20610,HCPCS,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,429.76,
COMPREHENSIVE METABOLIC PANEL,2800422,CDM,301,RC,80053,HCPCS,outpatient,,,73.5,55.13,,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.28,58.8,
SEND OUT CMP,2800912,CDM,301,RC,80053,HCPCS,outpatient,,,73.5,55.13,,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.28,58.8,
SFMC LIPASE SEND OUT,2801345,CDM,301,RC,83690,HCPCS,outpatient,,,73.5,55.13,,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.96,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.44,58.8,
SFMC AMYLASE SEND OUT,2801346,CDM,301,RC,82150,HCPCS,outpatient,,,73.5,55.13,,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.24,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.24,58.8,
HSV 1 IGM AB,2800362,CDM,302,RC,86695,HCPCS,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,59.2,
HSV 1 IGG AB,2800772,CDM,302,RC,86695,HCPCS,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,59.2,
Flowcytometry/tc add-on,2800944,CDM,311,RC,88185,HCPCS,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.31,65.62,
SFMC HSV 1 IGG AB,2801154,CDM,302,RC,86695,HCPCS,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,59.2,
XR CERVICAL SPINE 2 OR 3 VIEWS,4000034,CDM,320,RC,72040TC,HCPCS,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.7,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
PR XR CHEST FLUOROSCOPY IVIEW CXR,411039,CDM,972,RC,7102326,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
CONSCIOUS SED  < AGE 5,1400049,CDM,450,RC,99151,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ALPHA-1  ANTITRYPSIN AB TOTAL,2800052,CDM,301,RC,82103,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,60,
ANAEROBIC CULTURE,2800065,CDM,306,RC,87073,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,60,
CULTURE-AFB ANY SITE-STAIN INCLUDED,2800203,CDM,306,RC,87116,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.4,60,
CULTURE-ENVIRONMENTAL,2801153,CDM,306,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
DHEA-SULFATE,2800240,CDM,301,RC,82627,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,78.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.11,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.23,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.34,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.11,78.52,
DIGOXIN,2800241,CDM,301,RC,80162,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,60,
DILANTIN LEVEL TOTAL,2800243,CDM,301,RC,80185,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,60,
EBV TITER EARLY ANTIGEN,2800258,CDM,302,RC,86663,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.56,60,
SFMC SOMATOMEDIN C LEVEL,2800386,CDM,301,RC,84305,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,69.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.63,69.32,
MYCOPLASMA IGM,2800441,CDM,302,RC,86738,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,60,
Q FEVER ANTIBODIES,2800522,CDM,302,RC,86638,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.06,60,
CULTURE-AFB SMEAR & CULTURE,2800754,CDM,306,RC,87116,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.4,60,
CULTURE-AEROBIC & ANAEROBIC,2800860,CDM,306,RC,87075,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.73,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.15,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.73,60,
DRUG CONFIRMATION-TCA,2801005,CDM,301,RC,80334,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.84,60,
PROINSULIN,2801025,CDM,300,RC,84206,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.34,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,34.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.69,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.03,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.34,62.9,
SFMC ANAEROBIC CULTURE,2801143,CDM,306,RC,87073,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.66,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,60,
SFMC EBV TITER EARLY ANTIGEN,2801181,CDM,302,RC,86663,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.56,60,
SFMC CULTURE-AFB SMEAR & CULTURE,2801182,CDM,306,RC,87116,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.4,60,
SFMC MYCOPLASMA IGM,2801254,CDM,302,RC,86738,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,60,
SFMC ALPHA-1  ANTITRYPSIN AB TOTAL,2801259,CDM,301,RC,82103,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,60,
BB ANTIBODY SCREEN,3000001,CDM,300,RC,86850,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.21,74.09,
BB PER ANTIGEN GRP II,3000040,CDM,300,RC,86905,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,479.01,
GASTROGRAFIN 120 ML,4000005,CDM,636,RC,Q9963,HCPCS,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
LOW OSMOLAR CONTRAST 300ML-349ML,4000016,CDM,636,RC,Q9962,HCPCS,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
XR ELBOW 2 VIEWS LT,4000144,CDM,320,RC,73070LT,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
PR XR CERVICAL SPINE MIN 4 VIEW,4010035,CDM,972,RC,7205026,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR CHEST OBLIQUES VIEWS,4010040,CDM,972,RC,7102226,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR CYSTOGRAM MIN 3 VIEW,4010048,CDM,972,RC,7443026,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR FLUORO-NEEDLE PLACEMENT,4010059,CDM,972,RC,7700226,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR IVP  RETROGRADE CYSTOURETHAGRAM,4010073,CDM,972,RC,7445026,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR LOOPOGRAM,4010078,CDM,972,RC,7442526,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR LUMBAR SPINE 5 VIEWS,4010081,CDM,972,RC,7211026,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR LUMBAR SPINE COMPLETE W BENDING,4010082,CDM,972,RC,7211426,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR SKULL COMP MIN 4 VIEWS,4010115,CDM,972,RC,7026026,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR VCUG,4010131,CDM,972,RC,7445526,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR FLUORO CVA PLACEMENT,4010190,CDM,972,RC,7700126,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR XR CHEST OBLIQUES VIEWS*,4011142,CDM,972,RC,7104826,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR US CAROTID DOPPLER COMPLETE BIL,4110010,CDM,972,RC,93880,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,158.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,158.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,158.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,158.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,120,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,105,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,45,158.59,
PR US THYROID HEAD/NECK,4110030,CDM,972,RC,7653626,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR US ARTERIAL DOPPLER UPPER EXT - LEFT,4110048,CDM,972,RC,9393126LT,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
PR US ARTERIAL DOPPLER UPPER EXT - RIGHT,4110049,CDM,972,RC,9393126RT,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
AQUATIC THERAPY 1 OR > AREAS EACH 15 MIN,5100555,CDM,420,RC,97113GP,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,70,
AQUATIC THERAPY 1 OR > AREAS EACH 15 MIN,5100556,CDM,430,RC,97113GO,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,70,
"Hepatitis A vacc (HepA), adult dosage,",6000202,CDM,636,RC,90632,HCPCS,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
Hepatitis A and hep B vacc adult dose,6000204,CDM,636,RC,90636,HCPCS,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
EST LEVEL 2 OV MOD -25,6000259,CDM,521,RC,9921225,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
URINE DRUG SCREEN SCC,6000318,CDM,300,RC,80305,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.3,60,
TELEHEALTH AUDIO ONLY,6000358,CDM,521,RC,G0071,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,60,
STRAPPING SHOULDER,6100087,CDM,270,RC,29240,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,171.6,
BIOPSY OF VULVA  ADDITIONAL LESION,6100114,CDM,521,RC,56606,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,786.48,
BIOPSY W/COLPOSCOPY ADD'L,6100140,CDM,521,RC,58110,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,239.17,
XR SINUSES LESS THAN 3 VIEWS,6100171,CDM,320,RC,70210TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
CHEST PA & LAT,6100178,CDM,320,RC,71020TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
RIBS UNILATERAL PLUS 1 VIEW CHEST,6100180,CDM,320,RC,71101TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
XR RIBS BILATERAL 3+ VIEWS WITHOUT CHEST,6100181,CDM,320,RC,71110TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
XR STERNUM 2 VIEWS,6100182,CDM,320,RC,71120,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,129.44,
XR SCOLIOSIS,6100185,CDM,320,RC,72069,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
HUMERUS X-RAY,6100194,CDM,320,RC,73060TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
KNEE 3 VIEWS,6100206,CDM,320,RC,73562TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
XR FOOT THREE VIEWS,6100212,CDM,320,RC,73630TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ABDOMEN FLAT AND ERECT,6100216,CDM,320,RC,74020TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
URINE DRUG SCREEN,6100222,CDM,300,RC,80300,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
INP CONSULT REHAB 2,6100250,CDM,521,RC,99252,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
HEP A INJ ADULT,6100260,CDM,636,RC,90632,HCPCS,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
HEPATITIS B VACCINE ADULT 20mcg,6100261,CDM,636,RC,90636,HCPCS,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
EST LEVEL 2 OV,6100391,CDM,521,RC,99212,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,134.33,
XR CHEST 1 VIEW,6100564,CDM,320,RC,71045,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.36,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,129.44,
CHEST PA & LAT,6100565,CDM,320,RC,71046TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
KUB XRAY,6100566,CDM,320,RC,74018TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
TELEHEALTH AUDIO ONLY,6100721,CDM,521,RC,G0071,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,60,
GUIDANCE FOR NEEDLE BREAST,6200177,CDM,360,RC,77032,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
DEBRIDEMENT;SKIN PARTIAL THICKNESS,6200332,CDM,510,RC,11040,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
DRAIN BREAST LESION ADD EACH ADDITIONAL,6200527,CDM,360,RC,19001,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,336.95,
DRUG SCREEN,6300034,CDM,300,RC,80100,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
EST LEVEL 2 OV,6300070,CDM,510,RC,99212,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,134.33,
RISK FACTOR ASSESSMENT TOOL,6300125,CDM,972,RC,96160,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.79,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,3.32,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,45,
BRIEF EMOTIONAL/BEHAVIORAL ASSESSMENT,6300193,CDM,972,RC,96127,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,4.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,4.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,4.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6.78,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,4.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,5.94,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,4.24,45,
XR CHEST,6900134,CDM,320,RC,71045,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.36,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,129.44,
KNEE 3 VIEWS,6900153,CDM,320,RC,73562TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
XR FOOT THREE VIEWS,6900156,CDM,320,RC,73630TC,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
AUDIO ONLY; VIRTUAL CHECKIN,6900217,CDM,982,RC,G0071,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,22.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,22.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,22.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.37,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,22.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,31.82,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,22.73,45,
"Hepatitis A vacc (HepA), adult dosage,",6900222,CDM,636,RC,90632,HCPCS,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
ANES ACCESS CENTRAL VENOUS CIRCULATION,7200001,CDM,370,RC,00532QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES ANORECTAL PROC,7200002,CDM,370,RC,00902QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES BRONCHOSCOPY,7200003,CDM,370,RC,00520QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES CLAVICLE & SCAPULA BIOPS,7200004,CDM,964,RC,00454QZ,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
ANES CLAVICLE & SCAPULA NOT SPEC,7200005,CDM,964,RC,00450QX,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
ANES CLO PROC LOWER LEG ANKLE FOOT,7200006,CDM,964,RC,01462QZ,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
ANES CLOSED CHEST PROC NOT SPEC,7200008,CDM,964,RC,00520QZ,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
ANES CLOSED CHST PROC UTIL 1 LUNG VENT,7200009,CDM,370,RC,00529QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES ELECTRICAL CONVERION ARRHYTHMIA,7200010,CDM,370,RC,00410QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES EXT ANT & PERINEUM RAD/MOD PROC,7200011,CDM,370,RC,00404QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES EXT ANT & PERINEUM RECON ON BRST,7200012,CDM,964,RC,00402QZ,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
ANES EXT ANT PERINEUM RAD/MOD BRST DI,7200013,CDM,370,RC,00406QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES EXT ANT TRUNK & PERINEUM NOT SP,7200014,CDM,370,RC,00400QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES HERNIA REP IN UP ABD NOT SPEC,7200015,CDM,370,RC,00750QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES HERNIA REP LOW ABD VENTRAL/INC,7200016,CDM,370,RC,00832QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES HERNIA REP UP ABD/LUMB/VENTRAL,7200017,CDM,370,RC,00752QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES HERNIA REPAIR LOW ABD NOT SPEC,7200018,CDM,370,RC,00830QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES I & D BUTTOCK,7200019,CDM,370,RC,00400QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES INT SYS ESP THY LAYX TRAC LYMP NECK,7200020,CDM,370,RC,00320QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES INT SYS HEAD  NECK  POST TRUNK,7200021,CDM,964,RC,00300QZ,HCPCS,outpatient,,,75,56.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45,45,
ANES INTRAPAR LOW ABD LAP NOT SPEC,7200022,CDM,370,RC,00840QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES INTRAPAR LOW ABD RADICAL HYSTEREC,7200023,CDM,370,RC,00846QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES INTRAPAR LOW ABD-LAP TUBAL/TRANSEC,7200024,CDM,370,RC,00851QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES INTRAPAR UP ABD INCL LAP,7200025,CDM,370,RC,00790QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES INTUBATION ENDOTRACH EMERG PROC,7200026,CDM,370,RC,31500QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,466.07,
ANES LOWER ANTERIOR ABD WALL NOT SPEC,7200027,CDM,370,RC,00800QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES LOWER POSTERIOR ABD WALL,7200028,CDM,370,RC,00820QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES LWR INT ENDO PROC-INTRO DIST-DOUD,7200029,CDM,370,RC,00810QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES MALE GENITALIA NOT SPEC,7200030,CDM,370,RC,00920QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES MALE GENITALIA VASECTOMY UNIL/BIL,7200031,CDM,370,RC,00921QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES OPEN PROC BONE TIBIA ANKLE FOOT RAD,7200032,CDM,370,RC,01482QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES OPEN PROC UP 2/3 FEMUR AMPUTATION,7200033,CDM,370,RC,01232QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES PATIENT OF EXT AGE UNDER 1/OVER 70,7200034,CDM,370,RC,99100QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES PERM TRANSVENOUS PACEMAKER INSERT,7200035,CDM,370,RC,00530QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES PROC EXTERNAL MIDDLE INNER EAR,7200036,CDM,370,RC,00120QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES PROC UPPER ARM/ELBOW,7200037,CDM,370,RC,01710QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES PROCEDURES ON RADIUS  ULNA  OR HAND,7200038,CDM,370,RC,01830QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES REPL CATH CENT VENOUS DEV W/SUBC,7200039,CDM,370,RC,36580QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,1560.65,
ANES SALIVARY GLANDS INC BIOPSY,7200040,CDM,370,RC,00100QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES TRANSU PROC-TRANSU RESEC BLADDER,7200041,CDM,370,RC,00912QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES TRANSURETHRAL PROC NOT SPEC,7200042,CDM,370,RC,00910QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES UNDESCENDED TESTES UNILATERAL,7200043,CDM,370,RC,00924QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES UP ANT ABD WALL PERCU LIVER BIOP,7200044,CDM,370,RC,00702QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES UP GI ENDO PROC PROX TO DUOD,7200045,CDM,370,RC,00740QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES UPPER ANT ABD WALL NOT SPEC,7200046,CDM,370,RC,00700QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES UPPER POSTERIOR ABD WALL,7200047,CDM,370,RC,00730QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES VAGINAL HYSTERECTOMY,7200048,CDM,370,RC,00944QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES VAGINAL PROC NOT SPEC,7200049,CDM,370,RC,00940QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES EYE CASES,7200051,CDM,370,RC,00142QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES LWR INT ENDO PROC-INTRO DIST-DOUD,7200052,CDM,370,RC,00811QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES UP GI ENDO PROC PROX TO DUOD,7200053,CDM,370,RC,00731QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES SCREENING COLONOSCOPY,7200054,CDM,370,RC,00812QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES UPPER & LOWER ENDOSCOPE,7200055,CDM,370,RC,00813QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES NRVS MSCL TNDNS BRSAE OF SHLDR AXIL,7200056,CDM,370,RC,01610QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
"ANES OPEN PROC UPPER 2/3 FEMUR, NOS",7200057,CDM,370,RC,01230QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES OPEN FX HIP JOINT; NOS,7200058,CDM,370,RC,01210QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES CLOSED PROC RADIUS ULNA WRIST HAND,7200059,CDM,370,RC,01820QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES CLOSED PROC HEAD/NECK STEM JOINT,7200060,CDM,370,RC,01620QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES ALL NERVE MUSCLE TENDON OF UPPR LEG,7200061,CDM,370,RC,01250QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
INJECTION ANES AGENT BRACHIAL PLEXUS SIN,7200062,CDM,370,RC,64415,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1259.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1180.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,1259.46,
ANES OPEN PROC HIP/TTL HIP ARTHROPLASTY,7200065,CDM,370,RC,01214QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
"ANES ALL NRVS, MUSCLE OF ARM WRIST HAND",7200067,CDM,370,RC,01810QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES CLSD PROCD UPPER ENDS TIB FIB PATEL,7200068,CDM,370,RC,01390QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES OPEN PROCEDURES ELBOW NOS,7200069,CDM,370,RC,01740QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANESOPEN ARTHROSCOPIC HUMERAL HEAD/NECK,7200073,CDM,370,RC,01630QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES ON ARTERIES OF LEG NOS,7200074,CDM,370,RC,01500QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES OPEN ARTHROSCOPIC PROC KNEE JOINT,7200075,CDM,370,RC,01402QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
SFMC MYASTHENIA GRAVIS PANEL,2801303,CDM,301,RC,83520,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,22.45,130,,,other,Not separately reimbursable for outpatient setting,22.45,130,,,other,Not separately reimbursable for outpatient setting,22.45,130,,,other,Not separately reimbursable for outpatient setting,22.45,130,,,other,Not separately reimbursable for outpatient setting,22.45,130,,,other,Not separately reimbursable for outpatient setting,22.45,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,8.63,45.72,
"ANES ON NERVES, MUSCLE LOWER LEG/FOOT",7200076,CDM,370,RC,01470QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
"ANES OPEN PROCEDURES UPPER TIB,FIB,PAT",7200077,CDM,370,RC,01392QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
"ANES OPEN PROC LOWR LEG, ANKLE, FOOT NOS",7200078,CDM,370,RC,01480QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES CARDIAC CORONARY ANGIO/VENTRICULOGR,7200079,CDM,370,RC,01920QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES FOR VAGINAL PX; HYSTEROSCOPY/HYSTER,7200080,CDM,370,RC,00952QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ANES FOR DIAGNOSTIC ARTERIOGRAPHY/VENOGR,7200081,CDM,370,RC,01916QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
"ANES FOR ARTERIES OF UPPER LEG, INCL BYP",7200082,CDM,370,RC,01270QZ,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ISOVUE 300 MG 50ML,90000822,CDM,270,RC,Q9967,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ISOVUE 370 50 ML,90000824,CDM,255,RC,Q9967,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ISOVUE-M 200  10 ML,90005676,CDM,270,RC,Q9960,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ISOVUE-M 300 15ML,90005677,CDM,270,RC,Q9962,HCPCS,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
Narcan 2mg/2ml,3201252,CDM,636,RC,J2310,HCPCS,both,,,75.25,56.44,,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.28,75.25,
KETAMINE 100MG/ML,3205879,CDM,636,RC,J3490,HCPCS,both,,,75.95,56.96,,60.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.56,75.95,
KETAMINE 100MG/ML,3205882,CDM,636,RC,J3490,HCPCS,both,,,75.95,56.96,,60.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.56,75.95,
B PERTUSSIS IGA,2800104,CDM,305,RC,86615,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,60.8,
SFMC B PERTUSSIS IGG,2800105,CDM,305,RC,86615,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,60.8,
B PERTUSSIS IGM,2800106,CDM,305,RC,86615,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,60.8,
LIPID ASSOCIATED SIALIC ACID,2800688,CDM,301,RC,84275,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,60.8,
TRAMADOL SCREEN & CONFIRMATION URINE,2800862,CDM,301,RC,80307,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
DRUG SCREEN - WHOLE BLOOD,2801042,CDM,300,RC,80307,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
SFMC MANUAL LAB ORDER,2801324,CDM,300,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
DRUG SCREEN - WHOLE BLOOD,2801043,CDM,300,RC,80305,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.3,60.8,
DRUG SCREEN - WHOLE BLOOD,2801044,CDM,300,RC,80372,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.84,60.8,
OPIATES WHOLE BLOOD,2801380,CDM,300,RC,80307,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
EPSTEIN-BARR VIRUS ANTIBODY PROFILE,2801447,CDM,302,RC,86664,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.93,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.64,60.8,
UNLISTED THER/PROP/DIAG INJ/INF,6200510,CDM,360,RC,13101,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,858.6,
UNLISTED THER/PROP/DIAG INJ/INF,6200512,CDM,360,RC,96379,HCPCS,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,62.62,
HEMATOCRIT,2800328,CDM,305,RC,85014,HCPCS,outpatient,,,76.5,57.38,,61.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.08,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,61.2,
VITAMIN A,2800646,CDM,301,RC,84590,HCPCS,outpatient,,,76.5,57.38,,61.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.08,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.8,61.2,
TESTOSTERONE FREE & TOTAL,2801134,CDM,301,RC,84402,HCPCS,outpatient,,,76.5,57.38,,61.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.73,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.08,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.73,89.9,
SFMC VITAMIN A,2801249,CDM,301,RC,84590,HCPCS,outpatient,,,76.5,57.38,,61.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.08,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.8,61.2,
KETAMINE 200MG/20ML   (10mg/mL),3204801,CDM,636,RC,J3490,HCPCS,both,,,76.5,57.38,,61.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.78,76.5,
HEMATOCRIT SCC,6000182,CDM,305,RC,85014,HCPCS,outpatient,,,76.5,57.38,,61.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.08,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,61.2,
HEMATOCRIT,6100424,CDM,305,RC,85014,HCPCS,outpatient,,,76.5,57.38,,61.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.08,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,61.2,
FERRITIN,2800279,CDM,301,RC,82728,HCPCS,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.81,61.6,
HEP BE-ANTIBODY,2800337,CDM,302,RC,86707,HCPCS,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.78,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.78,61.6,
HEP BE AG,2800346,CDM,302,RC,87350,HCPCS,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,61.6,
SFMC FERRITIN SEND OUT,2801054,CDM,301,RC,82728,HCPCS,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.81,61.6,
SFMC HEP BE-ANTIBODY,2801245,CDM,302,RC,86707,HCPCS,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.78,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.78,61.6,
SFMC HEP BE AG,2801268,CDM,302,RC,87350,HCPCS,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.68,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,61.6,
PRIMAXIN 250MG,3200697,CDM,636,RC,J0743,HCPCS,both,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,77,
SOLU CORTEF 500MG,3200794,CDM,636,RC,J1720,HCPCS,both,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,77,
PRIMAXIN 250MG/NSS100ML,3202970,CDM,636,RC,J0743,HCPCS,both,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,77,
TRIM BENIGN SKIN LESIONS 2 TO 4 LESIONS,6200304,CDM,360,RC,11056,HCPCS,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,266.88,
"CA SCREEN, PELVIC /BREAST",6900099,CDM,982,RC,G0101,HCPCS,outpatient,,,77,57.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,26.86,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,26.86,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,26.86,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,26.86,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,26.86,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,26.86,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,26.86,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,37.6,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,26.86,46.2,
IONIZED-CA,2800388,CDM,301,RC,82330,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.84,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,62,
OXALATE,2800463,CDM,301,RC,83945,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.22,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.22,62,
PRIMIDONE LEVEL,2800489,CDM,301,RC,80184,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,62,
ROTAVIRUS,2800545,CDM,302,RC,86759,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.11,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.23,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.34,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.11,62,
STOOL FOR ROTAVIRUS,2800572,CDM,302,RC,86759,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.11,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.23,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.34,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.11,62,
TOBRAMYCIN,2800607,CDM,301,RC,80200,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.06,62,
SFMC ROTAVIRUS,2801192,CDM,302,RC,87425,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,62,
SFMC IONIZED-CA,2801244,CDM,301,RC,82330,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.84,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,62,
SFMC TOBRAMYCIN,2801246,CDM,301,RC,80200,HCPCS,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.06,62,
COLLECT BLOOD IMPLA VENOUS ACC DEVICE,1400008,CDM,761,RC,36591,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,171.6,
TESTOSTERONE TOTAL,2800599,CDM,301,RC,84403,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.9,91.19,
SOLU MEDROL 500MG,3200797,CDM,636,RC,J2930,HCPCS,both,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,78,
XR ELBOW-2 VIEWS RT,4000050,CDM,320,RC,73070TCRT,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
XR FINGERS MIN 2 VIEW RT,4000054,CDM,320,RC,73140TCRT,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
XR FINGERS MIN 2 VIEW LT,4000146,CDM,320,RC,73140TC,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
ABG ANALYSIS,5200006,CDM,301,RC,82803,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.1,62.4,
IPPB PER TREATMENT,5200051,CDM,410,RC,94640,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,283.02,
TELEMED 21-30 MIN AUDIO ONLY,6000357,CDM,521,RC,99443,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
TELEMED 21-30 MIN AUDIO ONLY,6100720,CDM,521,RC,99443,HCPCS,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
NEBULIZER,6900062,CDM,982,RC,94664,HCPCS,outpatient,,,78,58.5,,,,,,other,Not separately reimbursable for physician setting,9.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,15.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,15.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,9.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,9.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,15.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,15.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,9.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,24.37,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,15.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.32,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,9.33,46.8,
TELEMED 21-30 MIN AUDIO ONLY,6900216,CDM,982,RC,99443,HCPCS,outpatient,,,78,58.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,124.8,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,109.2,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,46.8,124.8,
PROTEIN C FUNCTIONAL,2800496,CDM,305,RC,85302,HCPCS,outpatient,,,78.5,58.88,,62.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,43.18,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.21,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,62.8,
SFMC PROTEIN C ANTIGEN,2801284,CDM,305,RC,85302,HCPCS,outpatient,,,78.5,58.88,,62.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,43.18,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.21,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,62.8,
SFMC PROTEIN C ACTIVITY,2801285,CDM,305,RC,85303,HCPCS,outpatient,,,78.5,58.88,,62.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.92,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,43.18,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.76,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,62.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.92,62.8,
ADENOCARD 6MG/2ML INJ,3202013,CDM,636,RC,J0153,HCPCS,both,,,79.5,59.63,,63.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.99,79.5,
BLOOD CLOT FACTOR V TEST,2800117,CDM,300,RC,85220,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.82,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.82,64,
FACTOR VII ACTIVITY,2800118,CDM,300,RC,85230,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,64,
GESTATIONAL DIABETES SCREEN,2800301,CDM,301,RC,82950,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,64,
MMR IMMUNITY PROFILE,2800431,CDM,300,RC,86765,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,64,
THEOPHYLLINE LEVEL,2800601,CDM,301,RC,80198,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.07,64,
WEST NILE ANTIBODY PART 2,2800886,CDM,302,RC,86789,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,64,
FACTOR XI ACTIVITY,2800971,CDM,300,RC,85270,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,64,
HIV,2801125,CDM,302,RC,87389,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.04,67.92,
CLEOCIN/NS IVPB : 900MG/50ML PM,3201008,CDM,636,RC,J0736,HCPCS,both,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,80,
PR MM Diag Dig Breast Tomosyn UNI,4011159,CDM,972,RC,7706126,HCPCS,outpatient,,,80,60,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,48,48,
CHEMICAL CAUTERIZATION OF TISSUE,6000149,CDM,521,RC,17250,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,266.88,
GESTATIONAL DIABETES SCREEN SCC,6000174,CDM,301,RC,82950,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,64,
SHORTARM SPLINT FOREARM TO HAND,6100086,CDM,300,RC,29125,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,290.49,
STRAPPING KNEE,6100088,CDM,270,RC,29530,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,171.6,
XR SKULL <4 VIEWS,6100173,CDM,320,RC,70250TC,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
XR SKULL COMP MIN 4 VIEWS,6100174,CDM,320,RC,70260,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,174.35,
GESTATIONAL DIABETES SCREEN NELHC,6100421,CDM,301,RC,82950,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,64,
XR MANDIBLE COMPLETE 4 VIEWS,6100460,CDM,320,RC,70110,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,174.35,
EKG WITH INTERPRETATION,6100487,CDM,730,RC,93000,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,124.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,124.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,124.29,
REMOVAL OF FOREIGN BODY (EXTERNAL EYE),6100502,CDM,521,RC,65205,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,234.67,
CHEMICAL CAUTERIZATION OF TISSUE,6100547,CDM,521,RC,17250,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,266.88,
DEBRIDEMENT WOUND W/O ANESTHESIA<20CM,6200085,CDM,360,RC,97597,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,266.87,
EKG WITHOUT INTERPRETATION,6900175,CDM,982,RC,93005,HCPCS,outpatient,,,80,60,,,,,,other,Not separately reimbursable for physician setting,7.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,5.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,5.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,5.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,7.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,7.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,5.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,5.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,7.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,9.17,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,5.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.02,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,5.73,48,
SB VISIT LEVEL I,7000021,CDM,524,RC,99308,HCPCS,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
DEPAKENE,2800236,CDM,301,RC,80164,HCPCS,outpatient,,,80.5,60.38,,64.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,64.4,
HEPATITIS DELTA VIRUS ANTIBODY,2800342,CDM,302,RC,86692,HCPCS,outpatient,,,80.5,60.38,,64.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.16,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.16,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.58,64.4,
VALPROIC ACID FREE,2800850,CDM,301,RC,80164,HCPCS,outpatient,,,80.5,60.38,,64.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,64.4,
VALPROIC ACID SEND OUT,2801428,CDM,301,RC,80164,HCPCS,outpatient,,,80.5,60.38,,64.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.28,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,64.4,
FLAGYL 500MG RTU PREMIX,3200311,CDM,636,RC,J1836,HCPCS,both,,,80.5,60.38,,64.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.39,80.5,
ALPHA-1 ANTITRYPSIN PHENOTYPE,2800053,CDM,301,RC,82104,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.23,64.8,
RAPID COVID ANTIGEN RMC,2801413,CDM,302,RC,87426,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,17.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.99,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.66,56.52,
CMV IGG,2800171,CDM,302,RC,86644,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,64.8,
TOXOPLASMOSIS IGG,2800609,CDM,302,RC,86777,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,64.8,
TOXOPLASMOSIS IGM,2800610,CDM,302,RC,86778,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.2,64.8,
VITAMIN E,2800700,CDM,301,RC,84446,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,64.8,
FACTOR VII ACTIVITY,2801067,CDM,302,RC,85230,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,64.8,
SFMC TOXOPLASMOSIS IGG,2801267,CDM,302,RC,86777,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,64.8,
SFMC VITAMIN E,2801274,CDM,301,RC,84446,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,64.8,
SFMC ALPHA-1 ANTITRYPSIN QNT & PHENOTYPE,2801281,CDM,301,RC,82104,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.23,64.8,
SARS COV-2 ANTIBODIES,2801410,CDM,302,RC,86769,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.06,67.4,
SARS COV-2 ANTIBODIES SEMI QUANTITATIVE,2801431,CDM,302,RC,86769,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.13,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.06,67.4,
GEODON 20MG INJ,3200338,CDM,636,RC,J3486,HCPCS,both,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,81,
EMG LTD SPEC MUSCLES,5600016,CDM,922,RC,95869,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,214.93,
EMG OTHER THAN PARASPINAL,5600017,CDM,922,RC,95870,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,171.6,
H-REFLEX/NERVE,5600019,CDM,922,RC,95934,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
SSR,5600027,CDM,922,RC,95923,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,171.6,
TRENIOGRAM 1 EXT,5600028,CDM,922,RC,95999,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,214.93,
SB DISCH/LEVEL I,7000019,CDM,524,RC,99315,HCPCS,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
ANGIOTENSIN 1 ENZYME TEST,2800067,CDM,301,RC,82164,HCPCS,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.3,65.6,
QUINIDINE,2800525,CDM,301,RC,80194,HCPCS,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.3,65.6,
ZONEGRAN,2800672,CDM,301,RC,80203,HCPCS,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,65.6,
PROTOPORPHYRIN FREE ERYTHROCYTE,2800857,CDM,301,RC,84202,HCPCS,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.17,65.6,
PR MM Screening Dig Breast Tomosyn BIL,4011161,CDM,972,RC,7706326,HCPCS,outpatient,,,82,61.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,49.2,49.2,
NM PH TC99M SULFUR COLLOID UP TO 20 mC,4400067,CDM,343,RC,A9541,HCPCS,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,65.6,
WRENCH KIT 5873W TORQUE,5890115,CDM,275,RC,C1722,HCPCS,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,65.6,
APOLIPOPROTEIN A-1,2800411,CDM,301,RC,82172,HCPCS,outpatient,,,82.5,61.88,,66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.74,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.54,66,
RUBEOLA TITER IGM,2800548,CDM,302,RC,86765,HCPCS,outpatient,,,82.5,61.88,,66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,66,
RUBEOLA TITER IGG,2801040,CDM,302,RC,86765,HCPCS,outpatient,,,82.5,61.88,,66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,66,
SFMC MEASLES DISEASE DIAGNOSIS,2801290,CDM,302,RC,86765,HCPCS,outpatient,,,82.5,61.88,,66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,66,
VANCOCIN 500MG INJ,3200905,CDM,636,RC,J3370,HCPCS,both,,,82.5,61.88,,66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.2,82.5,
CALCIUM GLUCONATE 1GM/50ML PM,3201847,CDM,636,RC,J0613,HCPCS,both,,,82.95,62.21,,66.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.38,82.95,
CALCIUM GLUCONATE 1000mg/50ML,3207041,CDM,636,RC,J0612,HCPCS,both,,,82.95,62.21,,66.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.38,82.95,
FOLATE,2800283,CDM,301,RC,82746,HCPCS,outpatient,,,83,62.25,,66.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.35,66.4,
EBV PROFILE CPT,2801448,CDM,302,RC,86665,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,23.58,130,,,other,Not separately reimbursable for outpatient setting,23.58,130,,,other,Not separately reimbursable for outpatient setting,23.58,130,,,other,Not separately reimbursable for outpatient setting,23.58,130,,,other,Not separately reimbursable for outpatient setting,23.58,130,,,other,Not separately reimbursable for outpatient setting,23.58,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,18.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,9.07,62.94,
FOLATE SENDOUT,2800958,CDM,301,RC,82746,HCPCS,outpatient,,,83,62.25,,66.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.35,66.4,
SFMC FOLATE SENDOUT,2801137,CDM,301,RC,82746,HCPCS,outpatient,,,83,62.25,,66.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,45.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.35,66.4,
PROSTHETIC TRNG INITIAL ENCOUNTER,5100553,CDM,420,RC,97761GP,HCPCS,outpatient,,,83,62.25,,66.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.4,70,
PROSTHETIC TRNG INITIAL ENCOUNTER,5100554,CDM,430,RC,97761GO,HCPCS,outpatient,,,83,62.25,,66.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.4,70,
HOME HEALTH PATIENT RECERTIFICATION,6900226,CDM,982,RC,G0179,HCPCS,outpatient,,,83,62.25,,,,,,other,Not separately reimbursable for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.02,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,54.26,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,62.02,
DOPAMINE 400mg/D5W250ML PRMIX,3200260,CDM,636,RC,J1265,HCPCS,both,,,83.5,62.63,,66.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.6,83.5,
DOPAMINE 400MG/D5W 500 ML,3201320,CDM,636,RC,J1265,HCPCS,both,,,83.5,62.63,,66.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.6,83.5,
MYOSITIS PANEL,2800902,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
MYOSITIS PANEL,2800903,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
MYOSITIS PANEL,2800904,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
MYOSITIS PANEL,2800905,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
MYOSITIS PANEL,2800906,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
MYOSITIS PANEL,2800907,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
MYOSITIS PANEL,2800908,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
MYOSITIS PANEL,2800909,CDM,302,RC,86235,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
CPK TOTAL AND ISOENZYMES,2801058,CDM,301,RC,82552,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.69,67.2,
ALPHA GALACTOSE IGE ANTIBODY,2801423,CDM,302,RC,86008,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,67.2,
SIMPLE REPAIR WOUND 12.6cm to 20.0cm,6000139,CDM,521,RC,12005,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,551.37,
SIMPLE REPAIR WOUND 12.6cm to 20.0cm,6100461,CDM,521,RC,12005,HCPCS,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,551.37,
ZOSYN 3.375GM INJ,3200978,CDM,636,RC,J2543,HCPCS,both,,,84.75,63.56,,67.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.1,84.75,
ANTINUCLEAR ANTIBODIES-DIRECT,2800082,CDM,302,RC,86038,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.13,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,68,
B12,2800107,CDM,301,RC,82607,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,68,
COMPLEMENT ANTIGEN-EACH COMPONET,2800183,CDM,302,RC,86160,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,68,
FRUCTOSAMINE,2800285,CDM,301,RC,82985,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.38,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.76,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.14,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.38,68,
FUNGAL SEROLOGY  ASPERGILLUS,2800289,CDM,302,RC,86606,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.52,68,
HCG QUANTITATIVE,2800320,CDM,301,RC,84702,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.52,68,
PNEUMOCOCCAL ANTIBODIES,2800376,CDM,301,RC,86609,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,68,
RHEUMATOID FACTOR,2800540,CDM,302,RC,86431,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.37,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.83,68,
VITAMIN B6,2800649,CDM,301,RC,84207,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.05,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,36.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.1,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.05,68,
PNEUMOCOCCAL ANTIBODY X14,2800703,CDM,301,RC,86609,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,68,
FUNGAL SEROLOGY,2800773,CDM,302,RC,86606,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.52,68,
GLUTATHIONE TOTAL,2800884,CDM,301,RC,82978,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.72,68,
B12 SENDOUT,2800957,CDM,301,RC,82607,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,68,
SFMC B12 SENDOUT,2801122,CDM,301,RC,82607,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,68,
HCG QUANTITATIVE SEND OUT,2801433,CDM,301,RC,84702,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.52,68,
BREVIBLOC 10MG/ML 10ML,3200088,CDM,636,RC,J1805,HCPCS,both,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,85,
BB MMA TEST #4,3000037,CDM,300,RC,86344,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,10.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,13.51,130,,,other,Not separately reimbursable for outpatient setting,13.51,130,,,other,Not separately reimbursable for outpatient setting,13.51,130,,,other,Not separately reimbursable for outpatient setting,13.51,130,,,other,Not separately reimbursable for outpatient setting,13.51,130,,,other,Not separately reimbursable for outpatient setting,13.51,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,10.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,10.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,10.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.62,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,5.19,28.2,
BB MMA TEST #5,3000038,CDM,300,RC,85007,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,4.94,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,1.9,8.84,
PR US GUIDANCE FOR VASCULAR ACCESS,4010184,CDM,972,RC,7693726,HCPCS,outpatient,,,85,63.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,51,51,
PR SCOL 2V,4011079,CDM,972,RC,7208226,HCPCS,outpatient,,,85,63.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,51,51,
PR US GUIDANCE FOR VASCULAR ACCESS,4110016,CDM,972,RC,7693726,HCPCS,outpatient,,,85,63.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,51,51,
NM PH GA-67 GALLIUM PER MCI,4400033,CDM,343,RC,A9556,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
"INJECTION, KELOID SCC",6000132,CDM,521,RC,11900,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,266.88,
MMR,6000224,CDM,636,RC,90707,HCPCS,both,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,85,
DEPRO PROVERA 150  MG,6000296,CDM,636,RC,J1050,HCPCS,both,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,85,
DEPO PROVERA 150 MG,6100013,CDM,636,RC,J1050,HCPCS,both,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,85,
ANAPROX 275 MG,3200003,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ANAPROX DS 550MG,3200004,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
"INJECTION, KELOID",6100068,CDM,521,RC,11900,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,266.88,
ANGIOMAX 250MG INJ,3200006,CDM,250,RC,,,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
ANTIFUNGAL CREAM(SECURA),3200007,CDM,637,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
ANTIVERT 25MG TAB,3200008,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ANUSOL HC CREAM,3200009,CDM,637,RC,,,outpatient,,,20.5,15.38,,16.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.25,16.4,
ANUSOL HC SUPP EACH,3200010,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ANUSOL OINT 1 OZ,3200011,CDM,637,RC,,,outpatient,,,6.7,5.03,,5.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.7,5.36,
ANUSOL SUPP,3200012,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
APRESOLINE 10MG TAB,3200013,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MMR,6100277,CDM,636,RC,90707,HCPCS,both,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,85,
APRESOLINE 25MG TAB,3200015,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SHORT LEG CAST(BELOW KNEE TO TOES),6100546,CDM,521,RC,29405,HCPCS,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,354.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,354.56,
PSYCHOTHERAPY 45 MIN-PATIENT OR FAMILY,6300185,CDM,972,RC,90836,HCPCS,outpatient,,,85,63.75,,,,,,other,Not separately reimbursable for physician setting,46.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,77.58,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,77.58,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,77.58,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,77.58,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,46.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,77.58,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,77.58,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,124.13,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,77.58,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,108.61,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,46.99,124.13,
NORMODYNE 5mg/mL 20mL INJ,3200624,CDM,636,RC,J1920,HCPCS,both,,,85.75,64.31,,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.51,85.75,
ARICEPT 10MG TAB,3200019,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ARICEPT 23MG TAB,3200020,CDM,637,RC,,,outpatient,,,9.75,7.31,,7.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.92,7.8,
ARICEPT 5MG TAB,3200021,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ARTANE 2MG,3200022,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ASPIRIN 325MG,3200023,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ASA ENTERIC TAB  325 MG,3200024,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ASA SUPP 120MG,3200025,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
ASCORBIC ACID 500MG TAB,3200027,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ASCRIPTIN TAB,3200028,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ASPIRIN SUPP 300MG,3200029,CDM,637,RC,,,outpatient,,,1.4,1.05,,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.12,
ASTELIN NASAL SPRAY,3200030,CDM,637,RC,,,outpatient,,,82.11,61.58,,65.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.04,65.69,
ATACAND 16MG TAB,3200031,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
ATARAX 25MG TAB,3200032,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ATARAX SYR 10MG/5ML (HYDROXYZINE HCI),3200033,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ATIVAN 0.5MG TAB,3200034,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ATIVAN 1MG TAB,3200035,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LABETALOL 5MG/ML  40 ML,3207131,CDM,636,RC,J1920,HCPCS,both,,,85.75,64.31,,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.51,85.75,
ER COLLECT BLOOD VENIPUNCTURE,1400046,CDM,450,RC,36415,HCPCS,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,68.8,
EBV TITER  NUCLEAR ANTIGEN,2800259,CDM,302,RC,86664,HCPCS,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.93,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.64,68.8,
FACTOR II ACTIVITY,2801083,CDM,300,RC,85210,HCPCS,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,68.8,
ATROVENT INHALER,3200040,CDM,637,RC,,,outpatient,,,301.02,225.77,,240.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.13,240.82,
ATROVENT NASAL SPRAY .03%,3200041,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
ATROVENT NASAL SPRAY .06%,3200042,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
AUGMENTIN 250MG/5ML 75 ML,3200043,CDM,637,RC,,,outpatient,,,106.6,79.95,,85.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.9,85.28,
AUGMENTIN 500MG TAB,3200044,CDM,637,RC,,,outpatient,,,1.2,0.9,,0.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.48,0.96,
AUGMENTIN 875MG TAB,3200045,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
AUGMENTIN XR 1GM TAB,3200046,CDM,637,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
AVALIDE 150/12.5MG TAB,3200048,CDM,637,RC,,,outpatient,,,4.25,3.19,,3.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.4,
AVAPRO 150MG TAB,3200049,CDM,637,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
AVAPRO 300MG TAB,3200050,CDM,637,RC,,,outpatient,,,4.25,3.19,,3.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.4,
AVODART 0.5MG TAB,3200051,CDM,637,RC,,,outpatient,,,4.55,3.41,,3.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,3.64,
SFMC EBV TITER  NUCLEAR ANTIGEN,2801175,CDM,302,RC,86664,HCPCS,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.93,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.64,68.8,
ER VISIT LEVEL II,6100348,CDM,521,RC,99282,HCPCS,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,206.44,
AZOPT 10 ML,3200054,CDM,637,RC,,,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.91,103.2,
BABY ASPIRIN 81MG TAB,3200055,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BACITRACIN 50MU VIAL,3200056,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
BACT. WATER 30ML,3200057,CDM,250,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
BACT.SOD.CHLOR.30ML,3200058,CDM,250,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
SFMC CPT 82542 CHG ONLY,2800955,CDM,301,RC,82542,HCPCS,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.13,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.04,69.6,
BACTRIM DS (SMP/TMX),3200060,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
BACTRIM PED SUSP 5ML,3200061,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BACTROBAN CREAM 15GM,3200062,CDM,637,RC,,,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
BACTROBAN OINT 22GM,3200063,CDM,637,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
BECONASE AQ NASEL SP,3200064,CDM,637,RC,,,outpatient,,,154.5,115.88,,123.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,62.17,123.6,
BENADRYL 25MG TABS,3200065,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BENADRYL CREAM 10Z,3200066,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
CATHETER GUIDING 6FR .072 H-STICK,5890016,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
BENADRYL SYR 12.5MG/5ML (ALCOHOL FREE),3200068,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BEN-GAY TOPICAL,3200069,CDM,637,RC,,,outpatient,,,4.25,3.19,,3.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.4,
BENICAR 20/12.5 TAB,3200070,CDM,637,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
BENICAR 20MG TAB,3200071,CDM,637,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
BENICAR 40/25 TAB,3200072,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BENICAR 40MG,3200073,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BENTYL 10MG CAP,3200074,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BENTYL 20 MG TABLET,3200075,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BENTYL ELIXIR 10MG/5ML,3200076,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
CATHETER GUIDING 6FR .072 MPB-1,5890018,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
BENZOIN SPRAY 6 OZ,3200078,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
BENZONATATE 200MG,3200079,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BETAPACE 80MG TAB,3200080,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BIAXIN 250MG/5ML 50ML,3200081,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
BIAXIN SUSP 125MG/5ML 50ML,3200082,CDM,637,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
BIAXIN XL 500MG TAB,3200083,CDM,637,RC,,,outpatient,,,4.6,3.45,,3.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.85,3.68,
CATHETER GUIDING 6FR .072 LCB 100CM,5890019,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CATHETER GUIDING 6FR .072 RCB 100CM,5890020,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CATHETER GUIDING 6FR .072 XBLAD 4.5 100C,5890021,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CATHETER GUIDING 6FR .072 XB LAD 4 100CM,5890022,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CATHETER GUIDING 6FR .072 XBLAD 3 100CM,5890023,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
BUMEX 1MG TAB,3200089,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
BUMEX 1MG/4ML INJ,3200090,CDM,250,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
BUMEX 2.5MG/10ML INJ,3200091,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
BUMEX TAB .5MG,3200092,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BUSPAR 10MG TAB,3200093,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BUSPAR 15MG TAB,3200094,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BUSPAR 5MG TAB,3200095,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BYSTOLIC 5MG TAB,3200096,CDM,637,RC,,,outpatient,,,2.25,1.69,,1.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.8,
CALAN 120 ER CAPSULE,3200097,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
CALAN 40MG TAB,3200098,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CALAN 5MG/2ML,3200099,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
CALAN SR 180MG CAP,3200100,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CALAN SR 240MG,3200101,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CALCITRIOL 0.5MCG (ROCALTROL),3200102,CDM,637,RC,,,outpatient,,,1.12,0.84,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
CALCIUM CHLORIDE 10% 10ML,3200103,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
CATHETER VISTA BRITE TIP XBLAD 3.5 PTFE,5890065,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CATHETER VISTA BRITE TIP XBLAD 3.5 2SH P,5890066,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CALEL-D TAB,3200106,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CAPOTEN 25MG TAB,3200107,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CAPOTEN 50MG TAB,3200108,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CARAFATE SUSP 1GM/10ML,3200109,CDM,637,RC,,,outpatient,,,6.7,5.03,,5.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.7,5.36,
CARDIZEM 25MG/5ML INJ,3200111,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
CARDIZEM 50MG/10ML INJ,3200112,CDM,250,RC,,,outpatient,,,112.5,84.38,,90,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.27,90,
CARDIZEM 60MG TAB,3200113,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CARDIZEM CD 120MG CAP,3200114,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CARDIZEM CD 180MG CAP,3200115,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
CARDIZEM CD 240MG CAP,3200116,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CARDIZEM LA 300MG TAB,3200117,CDM,637,RC,,,outpatient,,,2.25,1.69,,1.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.8,
CARDURA 2MG TAB,3200118,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CARDURA 4MG TAB,3200119,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CASODEX 50MG TAB,3200121,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CASTOR OIL 60ML,3200122,CDM,637,RC,,,outpatient,,,4.55,3.41,,3.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,3.64,
CATAFLAM 50MG TAB,3200123,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CATAPRES 0.1MG TAB,3200124,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CATAPRES 0.2MG TAB,3200125,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CATAPRES 0.3MG TAB,3200126,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CATAPRES-TTS 1 PATCH,3200127,CDM,637,RC,,,outpatient,,,20.65,15.49,,16.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.31,16.52,
CATAPRES-TTS 2 PATCH,3200128,CDM,637,RC,,,outpatient,,,34.75,26.06,,27.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.98,27.8,
CATAPRES-TTS 3 PATCH,3200129,CDM,637,RC,,,outpatient,,,48.2,36.15,,38.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.4,38.56,
CATHETER VISTA BRITE TIP XBLAD 4 2SH PTF,5890067,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CEFTIN 250MG TABS,3200131,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
CEFTIN 250MG/5ML 100ML,3200132,CDM,637,RC,,,outpatient,,,66.5,49.88,,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.76,53.2,
CEFTIN 500MG,3200133,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
CELEBREX 200MG CAP,3200134,CDM,637,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
CATHETER VISTA BRITE TIP XB3.5 PTFE,5890069,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CELEXA 20MG TAB,3200136,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CENTRUM MULTIVITAMAN TAB,3200138,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CEPACOL LOZENGES,3200139,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MOUTH WASH,3200140,CDM,637,RC,,,outpatient,,,2.7,2.03,,2.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.16,
CHLORASEPTIC SPRAY,3200141,CDM,637,RC,,,outpatient,,,8.78,6.59,,7.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.53,7.02,
CHRONULAC 20gm/30mL,3200142,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CIMETIDINE 200MG TAB (TAGAMET),3200143,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CIMETIDINE 300MG TAB,3200144,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SHEATH INTRODUCING IM,90005468,CDM,272,RC,C1887,HCPCS,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
CIPRO 250MG,3200146,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CATHETER GUIDING 670-060-00,90006280,CDM,272,RC,C1887,HCPCS,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
CIPRO 500MG TAB,3200148,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CLARINEX 5MG TAB,3200149,CDM,637,RC,,,outpatient,,,5.65,4.24,,4.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.52,
CLARITIN 10MG TAB,3200150,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CLARITIN D TAB,3200151,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
CLEOCIN 150MG CAPS,3200152,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CATHETER 6F .072 AL 1 100 CM 67203600,90006554,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CLIMARA 0.05MG PATCH,3200154,CDM,637,RC,,,outpatient,,,13.1,9.83,,10.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.27,10.48,
CLINDAMYCIN 75MG/5ML 100ML  SUSP,3200155,CDM,637,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
CATHETER 3 DRC 100CM 67213000,90006556,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
CLOBETASOL 0.05% 60MG OINTMENT,3200157,CDM,637,RC,,,outpatient,,,21.65,16.24,,17.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.71,17.32,
CO-ENZYME 60MG,3200158,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CO-ENZYMES Q10 30MG,3200159,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COGENTIN 1MG,3200160,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COLACE 100MG CAPS,3200161,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COLACE LIQ 50MG/5ML,3200162,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COLCRYS 0.6MG TAB,3200163,CDM,637,RC,,,outpatient,,,5.85,4.39,,4.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.35,4.68,
COLESTID 1GM TAB,3200164,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COLYTE 4 LITER,3200165,CDM,637,RC,,,outpatient,,,22.5,16.88,,18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.05,18,
COMBIGAN OPTH DROPS,3200166,CDM,637,RC,,,outpatient,,,97.55,73.16,,78.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.25,78.04,
COMBIVENT INHALER,3200167,CDM,637,RC,,,outpatient,,,240.75,180.56,,192.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.88,192.6,
COMPAZINE SUPP 25MG,3200168,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COMTAN 200MG,3200169,CDM,637,RC,,,outpatient,,,4.25,3.19,,3.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.4,
CATHETER 6 FR .072 AR A 100CM 67211000,90006559,CDM,270,RC,C1887,HCPCS,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
CORDARONE 200MG TAB,3200171,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COREG 12.5MG TAB,3200172,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COREG 25MG TAB,3200173,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COREG 3.125 TAB,3200174,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COREG 6.25MG TAB,3200175,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COREG CR 10MG CAP,3200176,CDM,637,RC,,,outpatient,,,5.25,3.94,,4.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.11,4.2,
COREG CR 20MG CAP,3200177,CDM,637,RC,,,outpatient,,,5.25,3.94,,4.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.11,4.2,
CORGARD 40MG TAB,3200178,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CORTANE-B OTIC DROP,3200179,CDM,637,RC,,,outpatient,,,11.5,8.63,,9.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.63,9.2,
CORTEF 10MG TAB,3200180,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CORTISPORIN OINT 1/2,3200181,CDM,637,RC,,,outpatient,,,132.48,99.36,,105.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.31,105.98,
CORTISPORIN OPTH SUSP 7.5mL,3200182,CDM,637,RC,,,outpatient,,,178.5,133.88,,142.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.83,142.8,
CORTISPORIN OTIC SOLUTION,3200183,CDM,637,RC,,,outpatient,,,208,156,,166.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,83.7,166.4,
CORTISPORIN OTIC SUSPENSION,3200184,CDM,637,RC,,,outpatient,,,5.65,4.24,,4.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.52,
COSOPT OPTH SOL,3200185,CDM,637,RC,,,outpatient,,,29.25,21.94,,23.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.77,23.4,
COUMADIN 10MG TAB,3200186,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COUMADIN 1MG TAB,3200187,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COUMADIN 2.5MG TAB,3200188,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COUMADIN 2MG TAB,3200189,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COUMADIN 3MG TAB,3200190,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COUMADIN 4MG TAB,3200191,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COUMADIN 5MG TAB,3200192,CDM,637,RC,,,outpatient,,,2.3,1.73,,1.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.84,
COUMADIN 7.5MG TAB,3200193,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COZAAR 100MG TAB,3200194,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
COZAAR 50MG TAB,3200195,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CRESTOR 10MG TAB,3200196,CDM,637,RC,,,outpatient,,,7.93,5.95,,6.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.19,6.34,
CRESTOR 20MG TAB,3200197,CDM,637,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
CATHETER 6F .072 MPA 1 100CM 67227000,90006561,CDM,278,RC,C1887,HCPCS,both,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,87,
C DIFFICILE,2800124,CDM,302,RC,87493,HCPCS,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.63,88.22,
CYANOCOBALAMIN 1000MCG TAB,3200200,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CYCLOSPORIN 100MG,3200201,CDM,637,RC,,,outpatient,,,11.02,8.27,,8.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.82,
CYMBALTA 20MG,3200202,CDM,637,RC,,,outpatient,,,5.95,4.46,,4.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.39,4.76,
CYMBALTA 30MG CAP,3200203,CDM,637,RC,,,outpatient,,,6.75,5.06,,5.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.72,5.4,
CYMBALTA 60MG,3200204,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CYTOTEC 200MCG,3200205,CDM,637,RC,,,outpatient,,,1.3,0.98,,1.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.52,1.04,
DANTRIUM I.V.,3200206,CDM,636,RC,,,both,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,252,
17 KETOSTEROIDS 2,2800893,CDM,300,RC,82533,HCPCS,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.15,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,70.4,
C DIFFICILE AMPLIFIED DNA,2801172,CDM,302,RC,87493,HCPCS,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,48.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,37.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.63,88.22,
BB CROSSMATCH,3000017,CDM,300,RC,86920,HCPCS,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.09,232.4,
CATHETER GUIDE (670-066-00,90006276,CDM,278,RC,C1887,HCPCS,both,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,88,
DECADRON ELIXIR,3200211,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DECLOMYCIN 150MG TAB,3200212,CDM,637,RC,,,outpatient,,,4.3,3.23,,3.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.73,3.44,
DECONEX TAB,3200213,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CATHETER 6F .072 XB 3.5 100CM 67205400,90006557,CDM,278,RC,C1887,HCPCS,both,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,88,
DELSYM 60mg/10mL,3200215,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
SFMC PROTEIN S FUNCTIONAL,2800498,CDM,305,RC,85306,HCPCS,outpatient,,,88.5,66.38,,70.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.68,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,70.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,70.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.66,70.8,
CONSCIOUS SEDATION > 5 YEARS OR OLDER,1400048,CDM,450,RC,99144,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
ER INTRAMUSCULAR INJECTION,1400109,CDM,260,RC,96372,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,99.71,
DEMADEX 20MG TAB,3200219,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DEPAKENE 250MG/5ML,3200220,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DEPAKOTE 125MG SPRINKLES,3200221,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DEPAKOTE 250MG TAB,3200222,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DEPAKOTE DR 500MG TAB,3200223,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DEPAKOTE ER 250MG,3200224,CDM,637,RC,,,outpatient,,,2.35,1.76,,1.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.88,
DEPAKOTE ER 500MG,3200225,CDM,637,RC,,,outpatient,,,4.88,3.66,,3.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,3.9,
ER INTRAMUSCULAR INJECTION/MOD 59,1400110,CDM,450,RC,9637259,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
INTRAMUSTCULAR INJ. W/MODIFIER 59,1400111,CDM,260,RC,9637259,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
INJECTION ANTIBIOTIC,1400220,CDM,940,RC,9637259,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
DESYREL 50MG TAB (TRAZODONE),3200229,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DETROL LA 2MG,3200230,CDM,637,RC,,,outpatient,,,6.26,4.7,,5.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,5.01,
DETROL LA 4MG CAP,3200231,CDM,637,RC,,,outpatient,,,6.26,4.7,,5.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,5.01,
DEXTROSE 20% 500ML,3200232,CDM,250,RC,,,outpatient,,,22.5,16.88,,18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.05,18,
DEXTROSE 50% 500ML,3200233,CDM,250,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
DEXTROSE 50% 50ML,3200234,CDM,250,RC,,,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
DIABETA 5MG TAB,3200235,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DIAMOX 250MG TAB,3200236,CDM,637,RC,,,outpatient,,,2.4,1.8,,1.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.92,
INTRAMUSCULAR INJECTION,1400221,CDM,260,RC,9637259,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
DIFLUCAN 100MG TAB,3200238,CDM,637,RC,,,outpatient,,,1.25,0.94,,1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.5,1,
DIFLUCAN 10MG/ML SUSP 35ML,3200239,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
DIFLUCAN 150MG TAB,3200240,CDM,637,RC,,,outpatient,,,2.75,2.06,,2.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.11,2.2,
AMMONIA LEVEL,2800059,CDM,301,RC,82140,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.28,71.2,
MUMPS IGG,2800437,CDM,300,RC,86735,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.52,71.2,
DILANTIN 100MG CAP,3200243,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MUMPS TITER IGM,2800438,CDM,302,RC,86735,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.52,71.2,
PYRUVATE,2800521,CDM,301,RC,84220,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,71.2,
DILANTIN SUSP 125MG/5 ML,3200246,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
DILAUDID 2MG TAB,3200247,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DIMENHYDRINATE 50MG TAB(DRAMAMINE),3200248,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DIOVAN 160MG TAB,3200249,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
DIOVAN 80MG TAB,3200250,CDM,637,RC,,,outpatient,,,3.6,2.7,,2.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.45,2.88,
DIOVAN HCT 160/12.5MG TAB,3200251,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
DIOVAN HCT 160/25 TAB,3200252,CDM,637,RC,,,outpatient,,,4.93,3.7,,3.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.98,3.94,
AMMONIA LEVEL SEND OUT,2801032,CDM,301,RC,82140,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.28,71.2,
SFMC MUMPS IGG & IGM,2801265,CDM,300,RC,86735,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.52,71.2,
DITROPAN 5MG-TAB,3200255,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DITROPAN XL 5MG TAB,3200256,CDM,637,RC,,,outpatient,,,2.8,2.1,,2.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.13,2.24,
XR ANKLE 2 VIEWS RT,4000026,CDM,320,RC,73600TCRT,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
XR ANKLE 2 VIEWS LT,4000140,CDM,320,RC,73600TCLT,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,71.2,
DONNATAL ELIX 5ML,3200259,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
XRAY SOFT TISSUE NECK,6100176,CDM,320,RC,70360,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,129.44,
DOXYCYCLINE 100MG CAP,3200261,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DOXYCYCLINE 100MG IV,3200262,CDM,250,RC,,,outpatient,,,68.5,51.38,,54.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.56,54.8,
XR SACRUM AND COCCYX,6100190,CDM,320,RC,72220,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,129.44,
DULCOLAX 10MG SUPP,3200264,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DULCOLAX 5MG TABS,3200265,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DUO-DERM 4X4 CGF,3200266,CDM,272,RC,,,outpatient,,,18.5,13.88,,14.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.44,14.8,
DUO-DERM 8X8,3200267,CDM,272,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
XR ANKLE 2 VIEWS,6100209,CDM,320,RC,73600,HCPCS,outpatient,,,89,66.75,,71.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,129.44,
DURAGESIC 25MCG/HR,3200269,CDM,637,RC,,,outpatient,,,46.5,34.88,,37.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.71,37.2,
DURAGESIC 50MCG/HR.,3200270,CDM,637,RC,,,outpatient,,,70.5,52.88,,56.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.37,56.4,
DURAGESIC 75MCG/HR,3200271,CDM,637,RC,,,outpatient,,,106.5,79.88,,85.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.86,85.2,
DYAZIDE,3200272,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ECOTRIN TABS 5 GR (325MG),3200273,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EDECRIN INJ 50 MG,3200274,CDM,250,RC,,,outpatient,,,1034.6,775.95,,827.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,416.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,517.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,517.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,517.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,517.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,569.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,416.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,827.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,775.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,827.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,827.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,416.32,827.68,
EFFEXOR XR 37.5MG CAP,3200275,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EFFEXOR 50MG TAB,3200276,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EFFEXOR XR 75 MG,3200277,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EFFIENT 10MG TAB,3200278,CDM,637,RC,,,outpatient,,,7.3,5.48,,5.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.94,5.84,
ELAVIL 10MG TAB,3200279,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ELAVIL 25MG TABS,3200280,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ELAVIL 50MG TABS,3200281,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ELESTAT OPTH SOL 5ML,3200282,CDM,637,RC,,,outpatient,,,94.8,71.1,,75.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.15,75.84,
ELOCON CREAM .1% 15G,3200283,CDM,637,RC,,,outpatient,,,5.63,4.22,,4.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.5,
EMETROL DOSE 5ML,3200284,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EMLA CREAM,3200285,CDM,637,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
ENABLEX 7.5 MG TAB,3200286,CDM,637,RC,,,outpatient,,,5.55,4.16,,4.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.23,4.44,
ENLON PLUS 10MG/ML VIAL,3200287,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
TWOCAL HN LIQUID  240 ml  NO CHARGE,3200288,CDM,250,RC,,,outpatient,,,5.85,4.39,,4.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.35,4.68,
EPHEDRINE 50 MG INJ,3200290,CDM,250,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
THERAPEUTIC INJECTION ADM FEE,6900067,CDM,982,RC,96372,HCPCS,outpatient,,,89,66.75,,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,53.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.27,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.27,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.27,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.23,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,13.27,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.58,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.27,53.4,
EPINEPHRINE 1:10000  1MG/10ML,3200292,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
VANCOMYCIN 1.25GM/250mL PREMIX,3206145,CDM,636,RC,J3370,HCPCS,both,,,89.24,66.93,,71.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.91,89.24,
EPSOM SALTS,3200294,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
ANTITHROMBIN III ANTIGEN,2800085,CDM,305,RC,85301,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.4,72,
ERYTHROCIN 500MG BASE TAB,3200296,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
ERYTHROCIN 500MG TAB,3200297,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ERYTHROMYCIN 200MG/5ML,3200298,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
ESTRACE 1MG TAB,3200299,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ESTRACE 2MG TAB,3200300,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EVISTA 60MG TAB,3200301,CDM,637,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
EXELON 1.5MG CAP,3200302,CDM,637,RC,,,outpatient,,,5.18,3.89,,4.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.08,4.14,
EXELON 4.6/DAY PATCH,3200303,CDM,637,RC,,,outpatient,,,10.28,7.71,,8.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.14,8.22,
EXELON 9.5 MG PATCH,3200304,CDM,637,RC,,,outpatient,,,20.28,15.21,,16.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.16,16.22,
FEOSOL 325MG TAB,3200305,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ASSAY OF VITAMIN D,2800101,CDM,301,RC,82306,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.8,104.53,
FERROUS SULFATE LIQUID 300MG/5ML,3200307,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FIBERCON 625MG TAB,3200308,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FIORICET TAB,3200309,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
FISH OIL CAP 1000MG,3200310,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
THYROGLOBULIN QUANTITATIVE,2800602,CDM,302,RC,86800,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.95,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.95,72,
FLEETS ENEMA PED,3200312,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FLEETS ENEMA-NO CHARGE,3200313,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FLEETS M-OIL ENEMA,3200314,CDM,637,RC,,,outpatient,,,2.1,1.58,,1.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.85,1.68,
FLEXERIL 10MG,3200315,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FLOMAX 0.4MG CAP,3200319,CDM,637,RC,,,outpatient,,,1.4,1.05,,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.12,
FLONASE NASAL SPRAY,3200320,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
FLORINEF TAB 0.1MG,3200321,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FLOVENT INHAL.110MCG,3200322,CDM,637,RC,,,outpatient,,,163.38,122.54,,130.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.74,130.7,
FLOVENT INHALER 44MCG,3200323,CDM,637,RC,,,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.09,97.6,
THYROGLOBULIN COMPREHENSIVE,2800851,CDM,302,RC,84432,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.02,72,
FML .25% FORTE OPTH 5mL,3200325,CDM,637,RC,,,outpatient,,,174.89,131.17,,139.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.38,139.91,
FOLIC ACID 5MG/ML INJ,3200326,CDM,250,RC,,,outpatient,,,7.11,5.33,,5.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.86,5.69,
FOLTX TABLET,3200327,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FOLVITE TABS 1MG TAB,3200328,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROCALCITONIN,2800919,CDM,300,RC,84145,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.61,72,
FOSAMAX  70MG TAB,3200330,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
FOSPHENYTOIN(CEREBRYX)50MG/ML 10mL,3200331,CDM,250,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
METHADONE SERUM OR PLASMA,2800951,CDM,301,RC,80358,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.29,72,
THYROGLOBULIN COMP ADD ON CHARGE,2801226,CDM,300,RC,86800,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.95,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.95,72,
INSULIN LEVEL FREE AND TOTAL,2801311,CDM,301,RC,83527,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.47,72,
GARAMYCIN OPTH 5CC SOL,3200335,CDM,637,RC,,,outpatient,,,23.02,17.27,,18.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.42,
GARAMYCIN OPTH OINT,3200336,CDM,637,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
GEODON 20MG CAP,3200337,CDM,637,RC,,,outpatient,,,9.97,7.48,,7.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.01,7.98,
IMMATURE  PLATELET FRACTIONATED,2801446,CDM,305,RC,85055,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,71.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,46.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,46.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.87,72,
GEODON 40MG CAP,3200339,CDM,637,RC,,,outpatient,,,9.97,7.48,,7.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.01,7.98,
GI COCKTAIL 60ML,3200340,CDM,637,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
BB PER ANTIGEN GRP III,3000041,CDM,300,RC,86905,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,479.01,
GLUCERNA SELECT 1000ML,3200343,CDM,637,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
GLUCOPHAGE 500MG TAB,3200344,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLUCOPHAGE 850MG TAB,3200345,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLUCOPHAGE XR 500MG TAB,3200346,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLUCOSAMINE CHONDROITIN,3200347,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLUCOTROL 10MG TAB,3200348,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLUCOTROL 5MG TAB,3200349,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLUCOTROL XL 10MG TAB,3200350,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLUCOTROL XL 5MG TAB,3200351,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLYCERINE SUPP,3200352,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
GLYNASE 3MG TAB,3200353,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HABITROL PATCH 14MG (NICOTINE),3200354,CDM,637,RC,,,outpatient,,,1.75,1.31,,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.4,
HABITROL PATCH 21MG (NICOTINE),3200355,CDM,637,RC,,,outpatient,,,1.75,1.31,,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.4,
HABITROL PATCH 7MG (NICOTINE),3200356,CDM,637,RC,,,outpatient,,,1.75,1.31,,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.4,
HALDOL 1MG TABS,3200357,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HALDOL 5MG TAB,3200358,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HALDOL CONC 120mL,3200359,CDM,637,RC,,,outpatient,,,3.45,2.59,,2.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.39,2.76,
PT GAIT TRAINING 15 MIN,5100003,CDM,420,RC,97116GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PT MAN THERAPY TECH 15 MIN,5100005,CDM,420,RC,97140GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
OT MASSAGE 15 MIN,5100006,CDM,430,RC,97124GO,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
OT NEUROMUSCULAR RE-ED 15 MIN,5100007,CDM,430,RC,97112GO,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
OT THERAPY PROCEDURE 15 MIN,5100010,CDM,430,RC,97110GO,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PT GAIT TRAINING EA 15MIN,5100514,CDM,420,RC,97116GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
HEPATITIS B VACCINE  1ML,3200366,CDM,250,RC,,,outpatient,,,276.5,207.38,,221.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,111.26,221.2,
HESPAN 500ML,3200367,CDM,250,RC,,,outpatient,,,310.5,232.88,,248.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.95,248.4,
HIBICLENS 4% 120ML,3200368,CDM,637,RC,,,outpatient,,,3.6,2.7,,2.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.45,2.88,
HUMALOG 75/25 1 UNIT,3200369,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
OT MANUAL THERAPY EA 15MIN,5100515,CDM,430,RC,97140GO,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PT MASSAGE THERAPY EA 15 MIN,5100516,CDM,420,RC,97124GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
HURRICANE SPRAY/APPL,3200372,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
HYDREA 500MG CAP,3200373,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HYDROCHLOROTHIAZIDE 25MG TAB,3200374,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HYDROCORT OINT 0.5% 30MG,3200375,CDM,637,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
HYDROCORT OINT 1% 30GM,3200376,CDM,637,RC,,,outpatient,,,5.11,3.83,,4.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.06,4.09,
HYDROCORTISONE CREAM 1% 30GR,3200378,CDM,637,RC,,,outpatient,,,1.98,1.49,,1.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.58,
HYDROGEN PEROXIDE 4OZ,3200379,CDM,637,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
PT NEUROMUSCULAR REEDUCATION EA 15MIN,5100517,CDM,420,RC,97112GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PT THERAPEUTIC EXERCISES EACH 15MIN,5100519,CDM,420,RC,97110GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
HYDROXYZINE 10MG,3200382,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HYPERGEL 15GM,3200383,CDM,637,RC,,,outpatient,,,20.5,15.38,,16.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.25,16.4,
HYDROXYCHLORQUINE 200MG,3200384,CDM,637,RC,,,outpatient,,,5.23,3.92,,4.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.1,4.18,
HYTRIN 1MG CAP,3200385,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HYTRIN 5MG CAP,3200386,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HYZAAR 100MG/25 TAB,3200387,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HYZAAR 50/12.5 TAB,3200388,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ICAR-C TAB,3200389,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
IMDUR 30MG TAB,3200390,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
IMDUR 60MG TAB,3200391,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
IMITREX 100MG TAB,3200392,CDM,637,RC,,,outpatient,,,2.35,1.76,,1.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.88,
OT MANUAL THERAPY EA 15MIN,5100520,CDM,430,RC,97140GO,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
IMODIUM 2MG CAP,3200394,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
IMODIUM LIQUID 5ML,3200395,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
IMURAN 50MG,3200396,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PT MASSAGE THERAPY EA 15 MIN,5100521,CDM,420,RC,97124GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
INDERAL 10MG TAB,3200398,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
INDERAL 20MG TAB,3200399,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
INDERAL 80MG TAB,3200400,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
INDERAL LA 120MG CAP,3200401,CDM,637,RC,,,outpatient,,,1.12,0.84,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
INDERAL LA 60MG,3200402,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
INDERAL LA 80MG CAP,3200403,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
INDOMETHACIN 25MG CAP,3200404,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ORTHOTIC MGMT & TRAINING EACH 15 MINS,5100540,CDM,420,RC,97760GP,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
ORTHOTIC MGMT & TRAINING EACH 15 MINS,5100541,CDM,430,RC,97760GO,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
INSTA-GLUCOSE PKT,3200407,CDM,637,RC,,,outpatient,,,4.7,3.53,,3.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.89,3.76,
INTEGRA CAP,3200409,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
INTEGRILIN 200MG,3200410,CDM,250,RC,,,outpatient,,,1706,1279.5,,1364.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,686.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,853,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,853,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,853,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,938.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1364.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,686.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1364.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1279.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1364.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1364.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,686.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1364.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,686.49,1364.8,
INTEGRILIN 20MG,3200411,CDM,250,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
XR SHOULDER COMPLETE MIN 2 VIEW,6100193,CDM,320,RC,73030,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,129.44,
ISMO 20MG TAB,3200413,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ISONIAZID 300 MG,3200414,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ISORDIL 10MG ORAL TAB,3200415,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ISORDIL 20MG ORAL TAB,3200416,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ISORDIL TEMBID 40MG TAB,3200417,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ISUPREL 1mg/5ml,3200418,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
JANUVIA 100MG,3200419,CDM,637,RC,,,outpatient,,,17.6,13.2,,14.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.08,14.08,
JUVEN 1 PACK,3200422,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
K DUR 20MEQ TAB,3200423,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
KALTOSTAT  ROPE  2GM,3200424,CDM,637,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
CALCIUM ALGINATE/SILVER DRESSING,3200425,CDM,272,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
KAYEXALATE 15GM/ 60ML (SPS),3200426,CDM,637,RC,,,outpatient,,,13.35,10.01,,10.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.37,10.68,
XR HAND 3 VIEWS,6100200,CDM,320,RC,73130TC,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
XR BILATERAL STANDING KNEES AP ONLY,6100207,CDM,320,RC,73565,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,129.44,
KEFLEX 250MG 5ML,3200429,CDM,637,RC,,,outpatient,,,6.65,4.99,,5.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.68,5.32,
KEFLEX 250MG CAPS,3200430,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
KEFLEX 500MG CAPS,3200431,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NSG HOME DISCH LEVEL 1,6100244,CDM,525,RC,99315,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
INP CONSULT REHAB 3,6100251,CDM,521,RC,99253,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
KENALOG CR .025% 15G,3200434,CDM,637,RC,,,outpatient,,,6.91,5.18,,5.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.78,5.53,
KENALOG CR 0.1% 30 GM,3200435,CDM,637,RC,,,outpatient,,,7.15,5.36,,5.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.88,5.72,
KEPPRA 100MG/ML Solut 5ML,3200436,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
KEPPRA 500MG TAB,3200437,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTE",6100452,CDM,521,RC,58999,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,32.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,32.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.27,263.25,
KLONOPIN 0.5MG,3200439,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
K-LYTE DOSE 25MEG,3200440,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LAMICTAL 100MG TAB,3200441,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LAMISIL 250MG TAB,3200442,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LAMISIL CREAM 1%15GM,3200443,CDM,637,RC,,,outpatient,,,7.1,5.33,,5.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.86,5.68,
LANOXIN .125 MG TAB,3200444,CDM,637,RC,,,outpatient,,,1.53,1.15,,1.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.62,1.22,
LANOXIN .25 MG TABS,3200445,CDM,637,RC,,,outpatient,,,1.35,1.01,,1.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.08,
LANOXIN 0.05MG/ML ELXR 60ML,3200446,CDM,637,RC,,,outpatient,,,26.06,19.55,,20.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.49,20.85,
PEG TUBE REPLACEMENT 18FR,6200495,CDM,270,RC,99070,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
LANTISEPTIC OINT,3200448,CDM,637,RC,,,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,11.6,
LANTUS (INSULIN GLARGINE) 1 UNIT,3200449,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PEG TUBE REPLACEMENT 20FR,6200496,CDM,270,RC,99070,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PEG TUBE REPLACEMENT 24FR,6200497,CDM,270,RC,99070,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
LASIX 20MG TAB,3200452,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PEG TUBE REPLACEMENT 22FR,6200498,CDM,270,RC,99070,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
LASIX 40MG TAB,3200454,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LASIX 80MG TAB,3200455,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LASIX ORAL SOL 60ML,3200456,CDM,637,RC,,,outpatient,,,6.09,4.57,,4.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.45,4.87,
LEG CRAMP/QUININE TAB,3200457,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LESCOL 20MG CAP,3200458,CDM,637,RC,,,outpatient,,,4.2,3.15,,3.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.69,3.36,
LEVAQUIN 250MG TAB,3200459,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PEG REPLACEMENT KIT 16FR,6200499,CDM,270,RC,99070,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
LEVAQUIN 500MG TAB,3200461,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
XR HAND 3 VIEWS,6900149,CDM,320,RC,73130TC,HCPCS,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
LEVBID TAB,3200463,CDM,637,RC,,,outpatient,,,1.69,1.27,,1.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.35,
OBSERVATION PER HOUR W/TELEMETRY,300004,CDM,762,RC,G0378,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.84,100,,,case rate,100% Observation case rate,27.84,100,,,case rate,100% Observation case rate,27.84,100,,,case rate,100% Observation case rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91,,,,other,Not separately reimbursable for outpatient setting,91,,,,other,Not separately reimbursable for outpatient setting,91,,,,other,Not separately reimbursable for outpatient setting,91,,,,other,Not separately reimbursable for outpatient setting,91,,,,other,Not separately reimbursable for outpatient setting,91,,,,other,Not separately reimbursable for outpatient setting,91,,,,other,Not separately reimbursable for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.84,91,
LEVOPHED 4mg/4mL,3200465,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
LEVSIN 0.125MG TAB,3200466,CDM,637,RC,,,outpatient,,,1.18,0.89,,0.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.47,0.94,
ACID PHOSPHATASE-TOTAL,2800026,CDM,300,RC,84060,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,26.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.82,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,72.8,
LEXAPRO 10MG TAB,3200468,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LEXAPRO 20MG TAB,3200469,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LIBRAX CAP,3200470,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LIBRIUM 25MG CAPS,3200471,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LIBRIUM 5MG CAPS,3200472,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ANTI-CENTROMERE B,2800076,CDM,301,RC,86235,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,72.8,
COLD AGGLUTININ,2800176,CDM,305,RC,86157,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.03,72.8,
ETHANOL- BLOOD OR URINE,2800268,CDM,300,RC,80320,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.45,72.8,
HEMOGLOBIN PLASMA FREE,2800331,CDM,300,RC,83051,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,9.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,9.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.65,72.8,
LIDOCAINE 4%/5ML MPF,3200477,CDM,250,RC,,,outpatient,,,8.55,6.41,,6.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.44,6.84,
LIDOCAINE CARDIAC INJ 2% 100mg,3200478,CDM,250,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
LIDOCAINE PRE-MIX 2g(4mg/ml) in D5W500ml,3200479,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
LIDOCAINE VISCOUS 20ML,3200480,CDM,637,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
LIDOCAINE W EPI 1% 10MG/ML 50mL,3200481,CDM,250,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
LIDOCAINE W EPI 2% 20MG/ML 50mL,3200482,CDM,250,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
LIDODERM 5% PATCH,3200483,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
LEPTOSPIRA ANTIBODY,2800405,CDM,302,RC,86720,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.1,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.1,72.8,
LIORESAL 10MG TABS,3200485,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LIPITOR 10MG TAB,3200486,CDM,637,RC,,,outpatient,,,2.75,2.06,,2.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.11,2.2,
LIPITOR 20MG TAB,3200487,CDM,637,RC,,,outpatient,,,6.59,4.94,,5.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.65,5.27,
LIPITOR 40MG TAB,3200488,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
LIPOSYN 20% 500ML,3200489,CDM,250,RC,,,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,200,
LITHIUM 150MG CAP,3200490,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LITHIUM CARB 300MG CAP,3200491,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOMOTIL TABS,3200492,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MINOXIDIL 2.5MG TAB,3200493,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOPID 600MG-Tab,3200494,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOPRESSOR 100MG TAB,3200495,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOPRESSOR 50MG TAB,3200496,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOPRESSOR 5MG/5CC AMP,3200497,CDM,250,RC,,,outpatient,,,39.5,29.63,,31.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.89,31.6,
NORCO 5/325MG (HYDROCODONE) TAB,3200498,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LORTAB (HYDROCOD/APAP)10MG/500MG TB,3200499,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LORTAB ELIXIR 7.5/325/15mL,3200500,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOTENSIN 20MG TAB,3200503,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOTENSIN HCT 10/12.5 TAB,3200504,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOTENSIN HCT 20/12.5 TAB,3200505,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOTREL 10/20 CAP,3200506,CDM,637,RC,,,outpatient,,,2.2,1.65,,1.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.89,1.76,
LOTREL 5mg/10mg CAP,3200507,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOTREL 5/20 CAP,3200508,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LOTRIMIN CR 30 GM,3200509,CDM,637,RC,,,outpatient,,,3.7,2.78,,2.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.49,2.96,
VITAMIN C,2800650,CDM,300,RC,82180,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.89,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.94,72.8,
WEST NILE VIRUS AB  CSF,2800661,CDM,300,RC,86789,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,72.8,
ZINC SERUM OR PLASMA,2800670,CDM,300,RC,84630,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.69,72.8,
SFMC ZINC SERUM,2801299,CDM,300,RC,84630,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.69,72.8,
BB MMA TEST #2,3000035,CDM,300,RC,86970,HCPCS,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,72.8,
TETANUS TOXOID IM,3200842,CDM,636,RC,90714,HCPCS,both,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.62,91,
LOZOL 2.5MG TAB,3200517,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LTA KIT,3200518,CDM,637,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
LUMIGAN 0.01% OPTH SOL 2.5mL,3200519,CDM,637,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
LUNESTA 2MG TAB,3200520,CDM,637,RC,,,outpatient,,,7.86,5.9,,6.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.16,6.29,
LYRICA 100MG CAP,3200521,CDM,637,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
LYRICA 25MG CAP,3200522,CDM,637,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
LYRICA 50MG CAP,3200523,CDM,637,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
LYRICA 75MG CAP,3200524,CDM,637,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
M O M CONC 10ML,3200525,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MVI VITAMINS INJ,3200526,CDM,250,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
MAALOX 30ML LIQUID,3200527,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MACRODANTIN 100MG (MACROBID),3200528,CDM,637,RC,,,outpatient,,,1.93,1.45,,1.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.78,1.54,
MACRODANTIN 50MG,3200529,CDM,637,RC,,,outpatient,,,1.44,1.08,,1.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.58,1.15,
MAG CITRATE 10 OZ,3200530,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
MAGNESIUM OXIDE 400MG,3200531,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SHEATH INTRODUCNG 3DRC SH,90005467,CDM,278,RC,C1887,HCPCS,both,,,91.36,68.52,,73.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.76,91.36,
NICOTINE WHOLE BLOOD OR SERUM,2501016,CDM,301,RC,80323,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.08,73.6,
MARCAINE 0.25% 50mL,3200534,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
MAXIDE 25MG TAB,3200535,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MAXITROL OINT,3200536,CDM,637,RC,,,outpatient,,,1.51,1.13,,1.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.61,1.21,
CORTISOL PM,2800188,CDM,301,RC,82533,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.15,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,73.6,
MEGACE 40MG TAB,3200538,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MEGACE SUSP 40MG/ML,3200539,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MELATONIN 3MG TAB,3200540,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZARONTIN,2800669,CDM,301,RC,80168,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.17,73.6,
SALIVARY CORTISOL,2801015,CDM,301,RC,82533,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.15,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,73.6,
MEPERIDINE 50MG TABS,3200543,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NICOTINE & METABOLITE WHL BLOOD OR SERUM,2801018,CDM,301,RC,80323,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.08,73.6,
METAMUCIL DOSE,3200545,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
METANX TAB,3200546,CDM,637,RC,,,outpatient,,,1.2,0.9,,0.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.48,0.96,
METFORMIN 1000MG TAB (GLUCOPHAGE),3200547,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
METHADONE TAB 5MG,3200548,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
METOPROLOL 25MG TAB,3200549,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
METRONIDAZOLE 500MG TAB,3200550,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MEVACOR 20MG TAB,3200551,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MIACALCIN NASAL SPRY,3200552,CDM,637,RC,,,outpatient,,,59.5,44.63,,47.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.94,47.6,
MICARDIS 80MG TAB,3200553,CDM,637,RC,,,outpatient,,,4.38,3.29,,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.76,3.5,
MICRO-K TAB 8MEQ,3200554,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MICRO-K-10 MEQ (POTASSIUM CHLORIDE),3200555,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MIDAZOLAM SYRUP 2MG ML,3200556,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
MINERAL OIL 1 OZ,3200557,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MINOCIN 100MG CAPS,3200558,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MINOCIN 50MG CAP,3200559,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MIRAPEX 0.5MG,3200560,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MIRENA,3200561,CDM,250,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
MOBIC 7.5MG TAB,3200562,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MOM TAB,3200563,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Miconazole Antifungal 2% 30gm,3200564,CDM,637,RC,,,outpatient,,,2.98,2.24,,2.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.2,2.38,
MONOPRIL 10MG,3200565,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CORTISOL AM LEVEL,2801165,CDM,301,RC,82533,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.15,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,73.6,
MS CONTIN 30mg,3200567,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SFMC CORTISOL 3 TO 4 PM LEVEL,2801194,CDM,301,RC,82533,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.15,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,73.6,
MORPHINE TABS   IR 15MG,3200569,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MOTRIN 600MG TAB,3200570,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MOTRIN 800MG TAB,3200571,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MOTRIN/LIQUID 100MG/5ML,3200572,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MS CONTIN 15 MG,3200573,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MUCINEX DM TAB,3200574,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SFMC ZARONTIN,2801200,CDM,301,RC,80168,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.34,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.17,73.6,
SFMC NICOTINE & METABOLITE WB OR SERUM,2801301,CDM,301,RC,80323,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.08,73.6,
MULTAQ 400MG,3200577,CDM,637,RC,,,outpatient,,,8.1,6.08,,6.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.26,6.48,
MYCOLOG CREAM 15GM,3200578,CDM,637,RC,,,outpatient,,,18.6,13.95,,14.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.48,14.88,
NYSTATIN CREAM 15 GM,3200579,CDM,637,RC,,,outpatient,,,85.5,64.13,,68.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.41,68.4,
MYLICON CHEW TAB 80 MG (SIMETHICONE),3200580,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MYLICON DROPS 30ML,3200581,CDM,637,RC,,,outpatient,,,2.47,1.85,,1.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.99,1.98,
MYOFLEX OINT 2 OZ,3200582,CDM,637,RC,,,outpatient,,,1.75,1.31,,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.4,
MYSOLINE 50MG TAB,3200583,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NAMENDA 10MG TAB,3200584,CDM,637,RC,,,outpatient,,,4.1,3.08,,3.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.65,3.28,
NAMENDA 5MG TAB,3200585,CDM,637,RC,,,outpatient,,,4.1,3.08,,3.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.65,3.28,
NAPROSYN 250MG TAB,3200586,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NAPROSYN 375 TAB,3200587,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NAPROSYN 500MG TAB,3200588,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHYSICIAN SUPERVISION,5500010,CDM,985,RC,93016,HCPCS,outpatient,,,92,69,,,,,,other,Not separately reimbursable for physician setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,55.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,20.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,20.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,20.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,20.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,32.61,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,20.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,28.53,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.87,55.2,
NASACORT AQ,3200590,CDM,637,RC,,,outpatient,,,89.97,67.48,,71.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.2,71.98,
NASONEX NASAL SPRAY,3200591,CDM,637,RC,,,outpatient,,,142.68,107.01,,114.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.41,114.14,
NEOMYCIN 500MG TAB,3200592,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NEOSPORIN 30GM,3200593,CDM,637,RC,,,outpatient,,,5.38,4.04,,4.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.16,4.3,
NEOSPORIN OINT UD,3200594,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NEOSPORIN OPTH OINT,3200595,CDM,637,RC,,,outpatient,,,6.13,4.6,,4.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.47,4.9,
NEOSPORIN OPTH SOL,3200596,CDM,637,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
HOLTER EPATCH 3-7 DAYS PRO FEE,5500016,CDM,976,RC,93244,HCPCS,outpatient,,,92,69,,,,,,other,Not separately reimbursable for physician setting,18.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,55.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,22.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,22.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,22.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,18.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,22.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,22.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,18.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,36.42,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,22.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,31.86,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,18.11,55.2,
NEO-SYNEPHRINE SPRAY 0.5%,3200598,CDM,637,RC,,,outpatient,,,3.99,2.99,,3.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.19,
NEG PRESSURE WOUND THERAPY < 50 SQ CM,6200215,CDM,360,RC,97605,HCPCS,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,266.88,
NEURONTIN 100MG CAP,3200600,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NEURONTIN 300MG CAP,3200601,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NEURONTIN 400MG Cap,3200602,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NEURONTIN 600MG TAB,3200603,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NEUT 1 AMP 8.4% 10mL,3200604,CDM,250,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
NEW SKIN,3200605,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NIASPAN 500MG,3200606,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NILSTAT ORAL 60 CC,3200607,CDM,637,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NILSTAT SUSP 5ML,3200608,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NIPRIDE 50MG INJ,3200610,CDM,250,RC,,,outpatient,,,355.5,266.63,,284.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,143.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,284.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,143.05,284.4,
NITRO DUR 0.1MG/HR,3200611,CDM,637,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
NITRO DUR 0.2MG/HR,3200612,CDM,637,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
NITRO DUR 0.4MG/HR,3200613,CDM,637,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
NITRO PASTE,3200614,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NITRO PREMIX IV 50MG/250ML,3200615,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NITROSTAT 0.3 (25),3200616,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NITROSTAT 0.4,3200617,CDM,637,RC,,,outpatient,,,9.79,7.34,,7.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.94,7.83,
NIZORAL 2% CREAM 15GM,3200618,CDM,637,RC,,,outpatient,,,3.44,2.58,,2.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.38,2.75,
NIZORAL SHAMPOO,3200619,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NOLVADEX TABS 10MG,3200620,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NORCURON (VECURONIUM) 10mg INJ,3200621,CDM,250,RC,,,outpatient,,,35.75,26.81,,28.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.39,28.6,
NORMAL SALINE FLUSH 10ML,3200622,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NORMLGEL 15GM,3200623,CDM,637,RC,,,outpatient,,,17.25,12.94,,13.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.94,13.8,
BB BLOOD TYPING ABO,3000008,CDM,300,RC,86900,HCPCS,outpatient,,,92.25,69.19,,73.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.74,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,3.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,73.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,73.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.99,171.6,
NORVASC 10MG TAB,3200625,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NORVASC 2.5MG TAB,3200626,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NORVASC 5MG TAB,3200627,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MANNITOL 20% 250 ML PM,3207324,CDM,636,RC,J2150,HCPCS,both,,,92.82,69.62,,74.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.35,92.82,
HSV I & II  IGM,2800364,CDM,302,RC,86694,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,74.4,
INFLUENZA A RAPID,2800380,CDM,302,RC,87804,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.27,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.27,74.4,
NYSTATIN POWDER,3200631,CDM,637,RC,,,outpatient,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.03,77.6,
OCEAN SPRAY,3200632,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
OCUVITE  PRESERVISION,3200633,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
OPTIVAR .05% 6ML,3200634,CDM,637,RC,,,outpatient,,,68.8,51.6,,55.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.69,55.04,
OS-CAL 500mg Tab,3200635,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
OXYCONTIN ER 10MG TAB,3200638,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
OXYCONTIN 20MG TAB,3200639,CDM,637,RC,,,outpatient,,,10.85,8.14,,8.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.37,8.68,
INFLUENZA B RAPID,2800383,CDM,300,RC,8780459,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
PATANOL .1% EYE DROP 5mL,3200641,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
PAXIL 20MG TAB,3200642,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PAXIL CR 12.5MG TAB,3200643,CDM,637,RC,,,outpatient,,,2.95,2.21,,2.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.19,2.36,
MYSOLINE,2800444,CDM,301,RC,80188,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.29,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.29,74.4,
PORPHYRIN LEVEL,2800482,CDM,301,RC,84120,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.06,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.35,74.4,
PEN VK 250MG TAB,3200646,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PEN VK 500MG TAB,3200647,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PEPCID 20MG TAB,3200648,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PEPTO BISMOL LIQUID 30mL,3200649,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PERCOCET-5 TAB,3200650,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PERIACTIN 4MG TAB,3200651,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PERPHENAZINE 2MG TAB,3200652,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PERSANTINE 25MG TAB,3200653,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHENERGAN 12.5MG SUPP,3200654,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHENERGAN 25MG TAB,3200655,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
QUICK FLU,2800524,CDM,302,RC,87804QW,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
PHENERGAN DOSE V C 5ML,3200657,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHENERGAN GEL 50 MG/ML,3200658,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
VMA 24 HR URINE,2800655,CDM,300,RC,84585,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.75,74.4,
PHENERGAN SUPP 25MG,3200660,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHENERGAN SUPP 50MG,3200661,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
PHENERGAN SYR 6.25MG/5ML,3200662,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHENERGAN/CODEINE ELIXIR 5ML,3200663,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
PHENOBARB 1 GR TAB 60MG,3200664,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHENOBARB 1/2 GR 30MG,3200665,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHENOBARB ELIXIR 5ML,3200666,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
WEST NILE ANTIBODY,2800665,CDM,302,RC,86788,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,74.4,
PILOCAR 1% 2CC,3200668,CDM,637,RC,,,outpatient,,,27.11,20.33,,21.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.91,21.69,
PILOCARPINE 2% 15ML,3200669,CDM,637,RC,,,outpatient,,,28.55,21.41,,22.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.49,22.84,
PILOCARPINE 4% 15mL,3200670,CDM,637,RC,,,outpatient,,,30.15,22.61,,24.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.13,24.12,
ADENOVIRUS ANTIBODY,2800896,CDM,302,RC,86603,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,74.4,
PLAVIX 75MG TAB,3200672,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PLENDIL 5MG TAB,3200673,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
PLETAL 100MG TAB,3200674,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SFMC HSV IGM,2801151,CDM,302,RC,86694,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,74.4,
POLY-HIST FORTE TABLET 340-b,3200676,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
POLY-TUSSIN AC 5ML,3200677,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
POLY-TUSSIN DHC 5ML,3200678,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
POLYTUSSIN DM 5ML,3200679,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
POT CHL ELIXIR 10 %   20 MEQ/ 15mL,3200680,CDM,637,RC,,,outpatient,,,18.75,14.06,,15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.55,15,
POTASSIUM 99MG,3200681,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
POTASSIUM PHOS INJ 5ML,3200682,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
PRADAXA 150MG CAP,3200683,CDM,637,RC,,,outpatient,,,3.42,2.57,,2.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.38,2.74,
PRAVACHOL 20MG TAB,3200684,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PRECOSE 50MG TAB,3200685,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PRED FORTE 1% 5ML,3200686,CDM,637,RC,,,outpatient,,,230,172.5,,184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,92.55,184,
SFMC CPT 82785 CHG ONLY,2801204,CDM,301,RC,82785,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.23,74.4,
PREMARIN 0.3MG TAB,3200688,CDM,637,RC,,,outpatient,,,2.65,1.99,,2.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.07,2.12,
PREMARIN 0.45MG TAB,3200689,CDM,637,RC,,,outpatient,,,2.65,1.99,,2.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.07,2.12,
PREMARIN 0.625 TAB,3200690,CDM,637,RC,,,outpatient,,,2.65,1.99,,2.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.07,2.12,
PREMARIN 0.9MG TAB,3200691,CDM,637,RC,,,outpatient,,,2.65,1.99,,2.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.07,2.12,
PREMARIN 1.25MG TAB,3200692,CDM,637,RC,,,outpatient,,,2.65,1.99,,2.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.07,2.12,
SFMC WEST NILE ANTIBODY,2801211,CDM,302,RC,86788,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,74.4,
PREMARIN VAG CREAM,3200694,CDM,637,RC,,,outpatient,,,174,130.5,,139.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.02,139.2,
PRENATAL VITAMIN,3200695,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PREVACID 30MG SOLUTAB,3200696,CDM,637,RC,,,outpatient,,,5.1,3.83,,4.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.05,4.08,
SFMC HERPES SIMPLEX PROFILE,2801262,CDM,302,RC,86694,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,74.4,
SFMC VMA 24 HR URINE,2801266,CDM,300,RC,84585,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.75,74.4,
PRINIVIL 5MG,3200699,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PRISTIQ 50MG,3200700,CDM,637,RC,,,outpatient,,,5.45,4.09,,4.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,4.36,
PROAMATINE 10MG,3200701,CDM,637,RC,,,outpatient,,,1.1,0.83,,0.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.44,0.88,
BB BLOOD-SPECIAL - PRODUCTIVITY ONLY,3000013,CDM,390,RC,84244,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.99,77.67,
PROCALAMINE 1000ML,3200703,CDM,250,RC,,,outpatient,,,179.5,134.63,,143.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.23,143.6,
PROCARDIA 10MG CAP,3200704,CDM,637,RC,,,outpatient,,,1.1,0.83,,0.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.44,0.88,
PROCARDIA XL 30MG TAB,3200705,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
PROCARDIA XL 60MG TAB,3200706,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROCARDIA XL 90MG TAB,3200707,CDM,637,RC,,,outpatient,,,1.9,1.43,,1.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.76,1.52,
"IPOL (POLIO) VACCINE, INACTIVATED",6000226,CDM,636,RC,90713,HCPCS,both,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,93,
PROCHLORPERAZINE 5MG TAB,3200709,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROCTOFOAM HC 15GM,3200710,CDM,637,RC,,,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,42.4,
PROPYLTHIOURACIL 50mg,3200711,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROSCAR 5MG TAB,3200712,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
IPOL (POLIO) VACCINE,6100447,CDM,636,RC,90713,HCPCS,both,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,93,
PROTECTIVE OINTMENT(SECURA),3200714,CDM,637,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
PROTEINEX LIQUID 30ML,3200715,CDM,637,RC,,,outpatient,,,1.37,1.03,,1.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.55,1.1,
PROTONIX 20MG TAB,3200716,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROTONIX 40MG TAB,3200717,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROTONIX IV 40mg VIAL,3200718,CDM,250,RC,,,outpatient,,,95.5,71.63,,76.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.43,76.4,
"XR SPINE, THORASIC AND LUMBAR; 1 VIEW",6100704,CDM,320,RC,72081,HCPCS,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,129.44,
PROVENTIL 2MG TAB,3200720,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ALBUTEROL FOR RESP,3200721,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROVERA 10MG TAB,3200722,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROVERA 2.5MG TAB,3200723,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROVIGIL 100MG TAB,3200724,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
PROZAC 10MG CAP,3200725,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROZAC 20MG CAP,3200726,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROZAC LIQ. DOSE 5ML,3200727,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PULMICORT INHALER,3200728,CDM,637,RC,,,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,360,
PULMICORT RESPULES 0.25mg/2mL,3200729,CDM,250,RC,,,outpatient,,,9.15,6.86,,7.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.68,7.32,
PYRIDIUM 100MG TAB,3200730,CDM,637,RC,,,outpatient,,,2.29,1.72,,1.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.92,1.83,
PYRIDIUM 200 TAB,3200731,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
QUESTRAN LIGHT PKT,3200732,CDM,637,RC,,,outpatient,,,4.1,3.08,,3.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.65,3.28,
QUINAGLUTE DURATAB 324MG TAB,3200733,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
RANEXA 500MG TAB,3200734,CDM,637,RC,,,outpatient,,,4.54,3.41,,3.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.83,3.63,
ALPHA FETO PROTEIN,2800051,CDM,301,RC,82105,HCPCS,outpatient,,,94,70.5,,75.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.38,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.38,75.2,
CORTISOL FREE 24 HR URINE,2800187,CDM,301,RC,82530,HCPCS,outpatient,,,94,70.5,,75.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.73,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.06,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.35,75.2,
REGLAN 5MG TAB,3200737,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REGLAN ELIXIR 5MG/5ML,3200738,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REGLAN 10MG TAB,3200739,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REMERON 15MG TAB,3200740,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REQUIP 0.25MG TAB,3200741,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REQUIP 1MG TAB,3200742,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
RESTORIL 15MG CAP,3200743,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
RESTORIL 30MG CAP,3200744,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REVATIO 20MG TAB,3200745,CDM,637,RC,,,outpatient,,,20.64,15.48,,16.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.31,16.51,
RIFADIN 300MG CAP,3200746,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
RIFAMPIN IV 600MG,3200747,CDM,250,RC,,,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
RISPERDAL 0.25MG TAB,3200748,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
RISPERDAL 1MG TAB,3200749,CDM,637,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
RITALIN TABS 10MG,3200750,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PROCAINAMIDE PRONESTYL NAPA,2800490,CDM,301,RC,80192,HCPCS,outpatient,,,94,70.5,,75.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.37,75.2,
ROBAXIN 500MG TABS,3200752,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ROBAXIN 750 TABS,3200753,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ROBINUL INJ 0.2 MG,3200754,CDM,250,RC,,,outpatient,,,52.2,39.15,,41.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.01,41.76,
ROBITUSSIN 200MG/10ML SYR,3200755,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ROBITUSSIN AC 5ML,3200756,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ROBITUSSIN DM 10mL,3200757,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ROCALTROL 0.25MCG Tab,3200758,CDM,637,RC,,,outpatient,,,1.7,1.28,,1.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.36,
SFMC METHYLMALONIC ACID SERUM,2800707,CDM,301,RC,83921,HCPCS,outpatient,,,94,70.5,,75.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.81,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.6,75.2,
SFMC ALPHA FETO PROTEIN,2801180,CDM,301,RC,82105,HCPCS,outpatient,,,94,70.5,,75.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.38,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,51.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.38,75.2,
FLUBLOK QUAD,3205529,CDM,636,RC,90682,HCPCS,both,,,94.8,71.1,,75.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,75.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.7,117.44,
AMITRIPLYLINE,2800058,CDM,301,RC,80335,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,76,
ROMAZICON 0.1MG/ML 5ML INJ,3200763,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
RYTHMOL 150MG,3200766,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SANTYL OINT 30GM,3200767,CDM,637,RC,,,outpatient,,,205,153.75,,164,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.49,164,
SELEGILINE 5MG TAB,3200768,CDM,637,RC,,,outpatient,,,1.92,1.44,,1.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.77,1.54,
SENOKOT TAB,3200769,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SEREVENT INHALER,3200770,CDM,637,RC,,,outpatient,,,124.8,93.6,,99.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.22,99.84,
SEROQUEL 100MG TAB,3200771,CDM,637,RC,,,outpatient,,,7.4,5.55,,5.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.98,5.92,
SEROQUEL 25MG TAB,3200772,CDM,637,RC,,,outpatient,,,4.43,3.32,,3.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.78,3.54,
SEVO FLURANE 100ML,3200773,CDM,250,RC,,,outpatient,,,420,315,,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,169.01,336,
SHUR-CLENS 20ML,3200774,CDM,637,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
SILVADENE 50GM,3200775,CDM,637,RC,,,outpatient,,,11.79,8.84,,9.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.74,9.43,
SILVADENE CR 400GM,3200776,CDM,637,RC,,,outpatient,,,23.1,17.33,,18.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.3,18.48,
SILVADINE 25 GM,3200777,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
SILVER NITRATE STICK,3200778,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINEMET 10/100 TAB (10mg/100mg),3200779,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINEMET 25/100 TABS,3200780,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINEMET 25/250 TAB,3200781,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINEQUAN 10MG CAP,3200782,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINEQUAN 25MG TAB,3200783,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINGULAIR 10MG,3200784,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINGULAIR 5MG TAB,3200785,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SOD SULAMYD 15mL,3200786,CDM,637,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
SODIUM BICARB 10GR TAB,3200787,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SODIUM BICARB 50CC 8.4%,3200788,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
SODIUM CHLORIDE 0.9% 10ML FLUSH,3200789,CDM,250,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
SODIUM CHLORIDE CONC 23.4%,3200790,CDM,250,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CYSTIC FIBROSIS PROFILE PART 3,2800231,CDM,306,RC,83909,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,76,
CYSTIC FIBROSIS PROFILE X14,2800232,CDM,306,RC,83901,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,76,
CYSTIC FIBROSIS PROFILE X25,2800233,CDM,306,RC,83914,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,76,
FATS/LIPIDS FECES QUANT,2800274,CDM,301,RC,82710,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.4,76,
HOMOCYSTINE LEVEL,2800359,CDM,301,RC,83090,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,76,
MS PROFILE CSF AND SERUM,2800434,CDM,300,RC,82040,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.47,76,
TSH,2800618,CDM,301,RC,84443,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.4,76,
WEST NILE VIRUS AB  CSF,2800660,CDM,300,RC,86788,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,76,
SOMA 350MG TAB,3200799,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SORBITOL 30ML,3200800,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SPIRIVA INHALER (INST),3200801,CDM,637,RC,,,outpatient,,,81.16,60.87,,64.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.66,64.93,
TSH SEND-OUT,2801053,CDM,301,RC,84443,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.4,76,
STELAZINE 10MG,3200803,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
STERILE MINERAL OIL,3200804,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
SFMC WEST NILE VIRUS AB  CSF,2801212,CDM,300,RC,86788,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,76,
SFMC HOMOCYSTINE LEVEL,2801219,CDM,301,RC,83090,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.3,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,76,
SHAVING EPIDERMAL/DERMAL LESION <0.5CM,6000115,CDM,521,RC,11305,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,266.88,
HEPATITIS B (AGES 11-19) 2 DOSE,6000235,CDM,636,RC,90743,HCPCS,both,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,95,
SUDAFED 30MG,3200809,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SULAR 17MG TAB,3200810,CDM,637,RC,,,outpatient,,,10.65,7.99,,8.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.29,8.52,
SULAR 8.5MG TAB,3200811,CDM,637,RC,,,outpatient,,,5.46,4.1,,4.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.2,4.37,
SULINDAC 200MG TAB,3200812,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SUPRANE 240ML(DESFLURANE),3200813,CDM,250,RC,,,outpatient,,,275,206.25,,220,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,110.66,220,
SURFAK 240MG CAP,3200814,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYMBICORT 160/4.5 INHALER,3200815,CDM,637,RC,,,outpatient,,,82.92,62.19,,66.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.37,66.34,
SYMBICORT 80/4.5 INHALER,3200816,CDM,637,RC,,,outpatient,,,82.92,62.19,,66.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.37,66.34,
SYMMETREL CAP 100MG,3200817,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYMMETREL SYRUP 100MG/5ML,3200818,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYNTHROID .075MG TAB,3200819,CDM,637,RC,,,outpatient,,,1.15,0.86,,0.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.46,0.92,
SYNTHROID .088MG TAB,3200820,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
SYNTHROID 0.025MG TAB,3200821,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYNTHROID 0.05MG TAB,3200822,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYNTHROID 0.112MG TAB,3200823,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYNTHROID 0.125MG TAB,3200824,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYNTHROID 0.15MG TAB,3200825,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYNTHROID 0.175MG TAB,3200826,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SYNTHROID 0.1MG TAB,3200827,CDM,637,RC,,,outpatient,,,1.4,1.05,,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.12,
SYNTHROID 200MG INJ,3200828,CDM,250,RC,,,outpatient,,,47.5,35.63,,38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.11,38,
TAGAMET LIQ 300MG/5ML,3200829,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TALBOTS OINT oz,3200830,CDM,637,RC,,,outpatient,,,6.05,4.54,,4.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.43,4.84,
TAMIFLU 75MG CAP,3200831,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
Methimazole 10MG TAB,3200832,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TEARS LUBRICANT EYE DROPS 1/20Z,3200833,CDM,637,RC,,,outpatient,,,10.05,7.54,,8.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.04,8.04,
TEGRETOL 100MG  XR  TAB,3200834,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TEGRETOL 200MG TAB,3200835,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TENEX 1MG TAB,3200836,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TENORMIN 100MG TAB,3200837,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TENORMIN 25MG TAB,3200838,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TENORMIN 50MG TAB,3200839,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TESSALON PERLES 100MG PERLE,3200840,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FLU BLOCK VACCINE,6000354,CDM,636,RC,90682,HCPCS,both,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.7,117.44,
SHAVING EPIDERMAL/DERMAL LESION <0.5CM,6100056,CDM,521,RC,11305,HCPCS,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,266.88,
TETRACAINE 0.5% OPTH 2mL,3200843,CDM,637,RC,,,outpatient,,,4.21,3.16,,3.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.69,3.37,
THEO-DUR 200MG TAB,3200844,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
THEO-DUR 300MG TAB,3200845,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HEPATITIS B (AGES 11-19),6100292,CDM,636,RC,90743,HCPCS,both,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,95,
THIAMINE 100MG TAB,3200847,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FLU BLOCK VACCINE,6100710,CDM,636,RC,90682,HCPCS,both,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.7,117.44,
FHC-FLU BLOCK VACCINE,6900210,CDM,982,RC,90682,HCPCS,outpatient,,,95,71.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,57,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,117.44,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,102.76,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,57,117.44,
THORAZINE TAB 25MG,3200850,CDM,637,RC,,,outpatient,,,4.15,3.11,,3.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.67,3.32,
ARMOUR  THYROID TABLET 60MG,3200851,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CELL COUNT SEROUS FLUID,2800659,CDM,309,RC,89051,HCPCS,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.28,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.8,76.8,
TIGAN 300MG CAP,3200853,CDM,637,RC,,,outpatient,,,1.39,1.04,,1.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.11,
TIMENTIN 3.1GM,3200854,CDM,636,RC,,,both,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,59,
TIMOPTIC 0.25 SOLN OPTH,3200855,CDM,637,RC,,,outpatient,,,7.19,5.39,,5.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,5.75,
TIMOPTIC 0.5 SOLN OPTH,3200856,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
TISSUE EXAM BY PATHOLOGIST,2800927,CDM,301,RC,88304,HCPCS,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,123.86,
TOBRADEX OPTH OINT,3200858,CDM,637,RC,,,outpatient,,,170.52,127.89,,136.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.62,136.42,
TOBRADEX SOLN OPTH 2.5mL,3200859,CDM,637,RC,,,outpatient,,,154.25,115.69,,123.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,62.07,123.4,
TISSUE EXAM BY PATHOLOGIST,2800928,CDM,301,RC,88305,HCPCS,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,160.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,60.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.24,160.87,
TOBREX OPTH OINT,3200861,CDM,637,RC,,,outpatient,,,97.57,73.18,,78.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.26,78.06,
TOBREX SOLN OPTH,3200862,CDM,637,RC,,,outpatient,,,2.16,1.62,,1.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.87,1.73,
TOFRANIL 25MG,3200863,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TOPAMAX 100MG,3200864,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TOPAMAX 25MG,3200865,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TOPROL XL 100MG,3200866,CDM,637,RC,,,outpatient,,,1.16,0.87,,0.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.47,0.93,
TOPROL XL 25MG,3200867,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TOPROL XL 50MG,3200868,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TORADOL 10MG,3200869,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ANTI MYELIN ASSOCIATED GLYCOPROTEIN,2801035,CDM,301,RC,86256,HCPCS,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,76.8,
RISK FACTOR ASSESSMENT TOOL,6900066,CDM,982,RC,96160,HCPCS,outpatient,,,96,72,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,57.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3.79,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,2.37,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,3.32,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.37,57.6,
ANGITENSIN I-CONVERTING ENZYME (ACE),2800068,CDM,301,RC,82164,HCPCS,outpatient,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.3,77.6,
TRACRIUM 10mL,3200873,CDM,250,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
TRANDATE 200MG TABS,3200874,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TRANSDERM-SCOP PATCH,3200875,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
TRAVATAN .OO4% 2.5 ML,3200876,CDM,637,RC,,,outpatient,,,213.39,160.04,,170.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,85.87,170.71,
TRENTAL 400MG TAB,3200877,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TRICOR 145MG TAB,3200878,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
TRIDIL-AMP 50MG,3200879,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
TRUSOPT 2% 5ML,3200880,CDM,637,RC,,,outpatient,,,16.03,12.02,,12.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.45,12.82,
TUMS 500mg,3200881,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TUSSIONEX SUSP 5ML,3200882,CDM,637,RC,,,outpatient,,,2.82,2.12,,2.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.13,2.26,
TYGACIL 50MG INJ,3200883,CDM,250,RC,,,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
TYLENOL #3 TAB,3200884,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL 325MG TAB,3200885,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL DROPS 15ML,3200886,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
TYLENOL 160mg/5ml,3200887,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL ELIXIR-ADULT 20.3mL,3200888,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL EXTRA ST.  500MG,3200889,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL PM TAB,3200890,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL SUPP 120MG,3200891,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL SUPP 325MG,3200892,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL SUPP 650MG,3200893,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TYLENOL/ COD ELXIR 5mL,3200894,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ULTRACET TAB,3200895,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ULTRAM 50MG,3200896,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MS PROFILE CSF,2800435,CDM,300,RC,83873,HCPCS,outpatient,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.6,77.6,
RBC FOLATE,2800530,CDM,305,RC,82747,HCPCS,outpatient,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.82,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.95,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.82,77.6,
URECHOLINE 25MG TAB,3200899,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
UROXATRAL 10MG TAB,3200900,CDM,637,RC,,,outpatient,,,4.7,3.53,,3.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.89,3.76,
TOFRANIL,2800671,CDM,301,RC,80335,HCPCS,outpatient,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,77.6,
VALIUM 2MG TAB (DIAZ,3200902,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VALIUM 5MG TAB(DIAZ),3200903,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VALTREX 1GM TAB,3200904,CDM,637,RC,,,outpatient,,,2.71,2.03,,2.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.17,
SFMC ANGIOTENSIN CONVERTING ENZYME (ACE),2801203,CDM,301,RC,82164,HCPCS,outpatient,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.3,77.6,
DTAPO/IPV 4-6 YEARS,6000220,CDM,636,RC,90696,HCPCS,both,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.03,97,
VASELINE JELLY 2.5OZ,3200907,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VASOTEC 10MG TAB,3200908,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VASOTEC 1.25MG/1mL INJ,3200909,CDM,250,RC,,,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.5,98.4,
VASOTEC 2.5MG TAB,3200910,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VASOTEC 20MG TAB,3200911,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VASOTEC 5MG TAB,3200912,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DTAPO/IPV,6100272,CDM,636,RC,90696,HCPCS,both,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.03,97,
INFLUENZA VAC.  HIGH DOSE,3201601,CDM,636,RC,90662,HCPCS,both,,,97.25,72.94,,77.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.7,117.44,
VENTOLIN SYRUP,3200915,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
OBSERVATION INITIAL HOUR,300001,CDM,762,RC,G0378,HCPCS,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.84,100,,,case rate,100% Observation case rate,27.84,100,,,case rate,100% Observation case rate,27.84,100,,,case rate,100% Observation case rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98,,,,other,Not separately reimbursable for outpatient setting,98,,,,other,Not separately reimbursable for outpatient setting,98,,,,other,Not separately reimbursable for outpatient setting,98,,,,other,Not separately reimbursable for outpatient setting,98,,,,other,Not separately reimbursable for outpatient setting,98,,,,other,Not separately reimbursable for outpatient setting,98,,,,other,Not separately reimbursable for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.84,98,
VESICARE 5MG,3200917,CDM,637,RC,,,outpatient,,,6.84,5.13,,5.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.75,5.47,
VICOPROFEN,3200918,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VIGAMOX OPTH SOL,3200919,CDM,637,RC,,,outpatient,,,101.74,76.31,,81.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.94,81.39,
VISINE DROPS 1 OZ,3200920,CDM,637,RC,,,outpatient,,,6.18,4.64,,4.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.49,4.94,
VISTARIL 25MG CAPS,3200921,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CHLAMYDIA AB IGM,2800153,CDM,302,RC,86632,HCPCS,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.34,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.34,78.4,
VIT D 400 1U TAB,3200923,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VIT D 50000 UNITS CAP,3200924,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VITAMIN D 1000 IU TAB,3200925,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VITAMIN E 400 U,3200926,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VOLTAREN 50MG TAB,3200927,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VOLTAREN  DR 75MG,3200928,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VOSOL HC OPTH 10mL,3200929,CDM,637,RC,,,outpatient,,,189.5,142.13,,151.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.25,151.6,
VOSOL OTIC 15ML,3200930,CDM,637,RC,,,outpatient,,,24.95,18.71,,19.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.04,19.96,
VOSPIRE ER 4MG,3200931,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VYTORIN 10/20 TAB,3200932,CDM,637,RC,,,outpatient,,,5.42,4.07,,4.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.18,4.34,
WELCHOL 625MG TAB,3200933,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
WELLBUTRIN 75MG TAB,3200934,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
WELLBUTRIN SR 100MG TAB,3200935,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
WELLBUTRIN SR 150MG TAB,3200936,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
WELLBUTRIN XL 150MG TAB(once daily),3200937,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
XALATAN 0.005% 2.5ML OPTH,3200938,CDM,637,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
XANAX 0.25MG TAB,3200939,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
XANAX 0.5MG TAB,3200940,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MICROSOMAL ANTIBODIES,2800427,CDM,302,RC,86376,HCPCS,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.27,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.27,78.4,
LIVER-KIDNEY MICROSOMAL ABS,2800429,CDM,302,RC,86376,HCPCS,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.27,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.27,78.4,
VANCOMYCIN LEVEL (EACH),2800633,CDM,301,RC,80202,HCPCS,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,78.4,
SFMC MICROSOMAL ANTIBODIES,2801177,CDM,302,RC,86376,HCPCS,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.27,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,53.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.27,78.4,
XYLOCAINE JELLY 2%,3200945,CDM,637,RC,,,outpatient,,,49.5,37.13,,39.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.92,39.6,
XYLOCAINE OINT 5%,3200946,CDM,637,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
ZANAFLEX 4MG TAB,3200947,CDM,637,RC,,,outpatient,,,2.53,1.9,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.02,
ZANTAC 150MG TAB,3200948,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HOLTER EPATCH 8-14 DAYS PRO FEE,5500018,CDM,976,RC,93248,HCPCS,outpatient,,,98,73.5,,,,,,other,Not separately reimbursable for physician setting,19.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,58.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,25.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,25.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,19.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,19.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,25.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,25.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,19.87,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,40.08,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,25.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,35.07,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,19.87,58.8,
ZAROXOLYN 5MG,3200950,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZEMURON 10MG/ML 5ML VIAL,3200951,CDM,250,RC,,,outpatient,,,96.5,72.38,,77.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.83,77.2,
ZESTORETIC 20/12.5 TAB,3200952,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZESTRIL 10MG TAB,3200953,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZESTRIL 20MG TAB,3200954,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZESTRIL 5MG TAB,3200955,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZETIA 10MG TAB,3200956,CDM,637,RC,,,outpatient,,,5.36,4.02,,4.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.16,4.29,
BISOPROPOL/HCTZ 10/6.25,3200957,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
ZIAC 5MG TAB,3200958,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZINC 220MG  (ELIMENTAL 50 MG),3200959,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZINC OXIDE OINT TUBE,3200960,CDM,637,RC,,,outpatient,,,2.42,1.82,,1.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.94,
INSERTION NONINDWELLING BLADDER CATHETER,6200477,CDM,360,RC,51702,HCPCS,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.44,171.6,
THER/PROPH/DIAG INJ ADDON (-59 MODIFIER),1400253,CDM,260,RC,9637559,HCPCS,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.84,79.2,
AMPHETAMINES WHOLE BLOOD,2800061,CDM,300,RC,G0431,HCPCS,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.84,79.2,
FREE PHENYTOIN,2800284,CDM,301,RC,80186,HCPCS,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,54.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.76,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.76,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.88,79.2,
SFMC GASTRIN,2800296,CDM,301,RC,82941,HCPCS,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,54.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.81,79.2,
GHP TSH,2801398,CDM,301,RC,80050,HCPCS,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,55.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,45.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.73,79.2,
ZOCOR 10MG TAB,3200967,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZOCOR 20MG(SIMVASTATIN),3200968,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZOCOR 40 MG,3200969,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
XR LUMBAR SPINE 5 VIEWS,4000081,CDM,324,RC,72110TC,HCPCS,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.45,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.84,79.2,
TET TOXOID INJ ADM FEE,1400092,CDM,771,RC,90471,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,99.71,
ZOFRAN TAB 4MG ODT,3200972,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZOFRAN TAB 8MG,3200973,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZOLOFT 100MG TAB,3200974,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZOLOFT 25MG TAB,3200975,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZOLOFT 50MG,3200976,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZOSTRIX CREAM 45GM,3200977,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
ER TETANUS ADMINISTRATION,1400208,CDM,771,RC,90471,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,99.71,
ER TETANUS DIPHTHERIA ADMINISTRATION,1400209,CDM,771,RC,90471,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,99.71,
ZOVIRAX 15GM OINT,3200980,CDM,637,RC,,,outpatient,,,201.25,150.94,,161,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.98,161,
ZOVIRAX 200MG CAP,3200981,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TX-INJECTION ANTIBIOTIC IM,1600003,CDM,450,RC,96372,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,99.71,
ZYLOPRIM 100MG TAB,3200983,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZYLOPRIM 300MG TAB,3200984,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZYPREXA 5MG TAB,3200985,CDM,637,RC,,,outpatient,,,8.66,6.5,,6.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.48,6.93,
ZYRTEC 10MG TAB,3200986,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ZYRTEC D TABLET,3200987,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
ZYRTEC SYRUP 5ML(1MG/ML),3200988,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ANTI DIPTHERIA ANTIBODY,2800069,CDM,302,RC,86648,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.81,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.6,80,
ANTI-CCP,2800075,CDM,302,RC,86200,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.47,80,
ANTIPHOSPHOLIPID ANTIBODY,2800083,CDM,302,RC,86147,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.72,80,
ERYTHROCIN/NS IVPB : 500MG/100ML,3201009,CDM,636,RC,J1364,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,133.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,83.64,133.82,
CLINIMIX E 4.25/10NJECTION,3201036,CDM,250,RC,,,outpatient,,,149.7,112.28,,119.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.24,119.76,
NF-MIRALAX ORAL PWD FOR SOLN 17GM/1DOSE,3201037,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-ABILIFY ORAL TABLET 10MG,3201038,CDM,250,RC,,,outpatient,,,53.74,40.31,,42.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.62,42.99,
Abilify 10 mg tab,3201039,CDM,637,RC,,,outpatient,,,67.56,50.67,,54.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.19,54.05,
Abilify 5 mg,3201040,CDM,637,RC,,,outpatient,,,67.56,50.67,,54.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.19,54.05,
PULMICORT 0.5MG/2ML INH,3201041,CDM,250,RC,,,outpatient,,,6.85,5.14,,5.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.76,5.48,
CALIF ENCEPH AB IGM,2800134,CDM,302,RC,86651,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,80,
CALIF. ENCEPH AB IGG,2800135,CDM,302,RC,86651,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,80,
CARRINGTON MOISTURE BARRIER CREAM,3201044,CDM,637,RC,,,outpatient,,,4.15,3.11,,3.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.67,3.32,
NITRO DUR 0.3MG/HR,3201045,CDM,637,RC,,,outpatient,,,4.34,3.26,,3.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.75,3.47,
CAPTOPRIL 12.5MG TAB,3201046,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CELEXA 10MG TAB,3201047,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
TRAZODONE 100MG TAB,3201048,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EXELON 6MG CAP,3201049,CDM,637,RC,,,outpatient,,,3.18,2.39,,2.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.28,2.54,
MOTRIN 200MG TAB,3201050,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MUCINEX ER 600MG TAB,3201051,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CMV IGM,2800172,CDM,302,RC,86645,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.42,80,
ACTIVATED CHARCOAL WITH SORBITOL,3201053,CDM,637,RC,,,outpatient,,,8.75,6.56,,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.52,7,
CRYPTOSPORIDIUM EIA,2800199,CDM,300,RC,87328,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.82,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.11,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.91,80,
Aminosyn 8.5% 500 ml,3201055,CDM,250,RC,,,outpatient,,,53.55,40.16,,42.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.55,42.84,
Aminosyn 8.5% with electolytes 500 ml,3201056,CDM,636,RC,,,both,,,56.8,42.6,,45.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.86,56.8,
EAST.EQUINE ENCEPH AB IGG,2800254,CDM,302,RC,86652,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,80,
EAST.EQUINE ENCEPH AB IGM,2800255,CDM,302,RC,86652,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,80,
CiprofloxacinOpth 5mL,3201059,CDM,637,RC,,,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,76,
Dacriose Opth Sol (Eye Wash) 4 OZ,3201060,CDM,637,RC,,,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,11.6,
Relafen 500mg Tab,3201061,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-BIOTIN ORAL TABLET 1000MCG,3201062,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-ARAVA ORAL TABLET 20MG,3201063,CDM,636,RC,,,both,,,66.77,50.08,,53.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.87,66.77,
MIRALAX POWDER,3201064,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-BYETTA SUBCUTANEOUS SOLUTION 250MCG/1,3201065,CDM,637,RC,,,outpatient,,,1080.03,810.02,,864.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,434.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,540.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,540.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,540.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,594.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,434.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,434.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,864.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,810.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,864.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,434.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,864.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,434.6,864.02,
NF-ARIMIDEX TAB 1MG,3201066,CDM,636,RC,,,both,,,61.17,45.88,,48.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.61,61.17,
ALTACE 5MG TAB,3201067,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ALTACE 10MG TAB,3201068,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ALTACE 2.5MG TAB,3201069,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
AMARYL 2MG TAB,3201070,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
AMARYL 4MG TAB,3201071,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EBV TITER VIRAL CAPSID ANTIGEN IGG,2800260,CDM,302,RC,86665,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.07,80,
Racemic Epinephrine 2.25% 0.5ml,3201073,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-ZOLPIDEM ORAL TABLET 5MG,3201074,CDM,250,RC,,,outpatient,,,1.48,1.11,,1.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.18,
NF-CIPRO IV IV SOLN 400MG/200ML,3201076,CDM,250,RC,,,outpatient,,,0.56,0.42,,0.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.45,
NF-AMBIEN ORAL TABLET 5MG,3201077,CDM,250,RC,,,outpatient,,,16.28,12.21,,13.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.55,13.02,
NF-VICKS VAPORUB OINT 4.2%-2.6%-1.2%,3201078,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
AMBIEN 10MG TAB,3201080,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
AMBIEN 5MG TAB,3201081,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Phos-NaK Powder Pkt,3201082,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PHOS-LO  667mg Tab,3201083,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FLUVOXAMINE (LUVOX),2800282,CDM,301,RC,80332,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,80,
Tekturna 150mg Tab,3201087,CDM,637,RC,,,outpatient,,,3.25,2.44,,2.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.31,2.6,
Glycopyrrolate 1mg Tab,3201088,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Seroquel 50mg Tab,3201089,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Tetracycline 250mg Cap,3201090,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Tofranil 10mg Tab,3201091,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Urimar-T Tab,3201092,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VANTIN 200mg Tab,3201093,CDM,637,RC,,,outpatient,,,1.25,0.94,,1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.5,1,
Zomig 5mg Tab,3201094,CDM,637,RC,,,outpatient,,,32.4,24.3,,25.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.04,25.92,
Acyclovir 800mg Tab,3201095,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Aquaphor Oint,3201096,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
Altabax 1% Oint 15gm,3201097,CDM,637,RC,,,outpatient,,,106.65,79.99,,85.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.92,85.32,
EryPed 200mg/5ml Susp 100mL,3201098,CDM,637,RC,,,outpatient,,,164,123,,131.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.99,131.2,
Dexamethasone Opth Sol 0.1% 5mL,3201099,CDM,637,RC,,,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
Erythromycin Opth Oint 0.5%,3201100,CDM,637,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
LacriLube 1/8 oz Opth Eye Lubricant,3201101,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
Ocufen Opth Sol 0.03% 2.5mL,3201102,CDM,637,RC,,,outpatient,,,2.95,2.21,,2.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.19,2.36,
Voltaren Opth Sol 0.1% 2.5ml,3201103,CDM,637,RC,,,outpatient,,,7.25,5.44,,5.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.92,5.8,
HTLV-I/II,2800367,CDM,301,RC,86790,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,80,
Nafcillin 2gm Inj,3201105,CDM,250,RC,,,outpatient,,,104.78,78.59,,83.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.16,83.82,
Neosynephrine 1% 10mg/1mL Inj,3201106,CDM,636,RC,,,both,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,11,
ANCA PANEL EXTRA CHARGE,2800465,CDM,301,RC,83516,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,80,
Aminocaproic 250mg/mL 20mL Inj,3201108,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
WEST. EQUINE ENCEPH AB IGG,2800662,CDM,302,RC,86654,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,80,
WEST.EQUINE ENCEPH AB IGM,2800663,CDM,302,RC,86654,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,80,
Cetacaine Spray,3201111,CDM,637,RC,,,outpatient,,,51.5,38.63,,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.72,41.2,
Betamethasone Dip Cream 0.05% 15gm,3201112,CDM,637,RC,,,outpatient,,,31.1,23.33,,24.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.51,24.88,
Dermoplast Spray 2.75oz,3201113,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
Domeboro Powder Pkt,3201114,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Hydrocortisone Cream 2.5% 30gm,3201115,CDM,637,RC,,,outpatient,,,3.2,2.4,,2.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.29,2.56,
Thrombin 5000 IU,3201116,CDM,637,RC,,,outpatient,,,318.16,238.62,,254.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,159.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.03,254.53,
Neo-Synephrine 1% Nasal Cold & Sinus,3201117,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
Promethazine DM Syrup,3201118,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Bicitra Sol 500mg/334mg per 5mL,3201119,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Voltaren Gel 1% 100gm,3201120,CDM,637,RC,,,outpatient,,,52.55,39.41,,42.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.15,42.04,
Zovirax Cream 5gm,3201121,CDM,637,RC,,,outpatient,,,247,185.25,,197.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.39,197.6,
NF-TRIMETHOPRIM ORAL TABLET 100MG,3201123,CDM,250,RC,,,outpatient,,,5.58,4.19,,4.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.25,4.46,
NF-LISINOPRIL HCTZ ORAL TABLET 20MG-25MG,3201124,CDM,250,RC,,,outpatient,,,2.05,1.54,,1.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.64,
NF-BELLADONNA ALK W/ PHENOBARBITAL ORAL,3201125,CDM,250,RC,,,outpatient,,,1.36,1.02,,1.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.55,1.09,
D5 1/2NSS-K20 1000ML,3201126,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-ALDACTONE ORAL TABLET 100MG,3201127,CDM,637,RC,,,outpatient,,,3.17,2.38,,2.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.28,2.54,
NF-XIFAXAN ORAL TABLET 200MG,3201128,CDM,250,RC,,,outpatient,,,14.59,10.94,,11.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.87,11.67,
NF-PROAIR HFA AER PWD 0.09MG/1ACT,3201129,CDM,250,RC,,,outpatient,,,15.98,11.99,,12.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,12.78,
Aldactone 25mg Tab,3201130,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NSS/KCL 20MEQ 1000ML,3201131,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
Allegra 180mg Tab,3201132,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Aldomet 250mg Tab,3201133,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Amitiza 24mcg Cap,3201134,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
Amoxil 500mg Cap,3201135,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
FELBATOL SERUM,2800878,CDM,301,RC,80150,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,80,
IMMUNOHISTO ANTIBODY SLIDE,2800934,CDM,301,RC,88342,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,111.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,111.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,111.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,83.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,83.29,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55,232.4,
NF-ALLEGRA ALLERGY ORAL TABLET 60MG,3201138,CDM,250,RC,,,outpatient,,,2.96,2.22,,2.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.19,2.37,
NF-BENICAR ORAL TABLET 5MG,3201139,CDM,250,RC,,,outpatient,,,86.18,64.64,,68.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.68,68.94,
NF-PYRIDOXINE HCL TABLET 100MG,3201140,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
Sodium Cl 3% inhalation,3201141,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NF-DALIRESP ORAL TABLET 500MCG,3201142,CDM,250,RC,,,outpatient,,,25.53,19.15,,20.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.27,20.42,
NF-ZYPREXA ORAL TABLET 2.5MG,3201144,CDM,250,RC,,,outpatient,,,54.06,40.55,,43.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.75,43.25,
NF-TEGRETOL-XR TAB ER 100MG,3201145,CDM,250,RC,,,outpatient,,,2.46,1.85,,1.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.99,1.97,
NF-ZYPREXA ORAL TABLET 2.5MG,3201146,CDM,250,RC,,,outpatient,,,54.06,40.55,,43.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.75,43.25,
NF-VIVELLE TRANSDERM PATCH 0.025MG/24HRS,3201147,CDM,250,RC,,,outpatient,,,35.17,26.38,,28.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.15,28.14,
NF-POTASSIUM CHLORIDE 10MEQ ORAL CAPSULE,3201148,CDM,250,RC,,,outpatient,,,19.56,14.67,,15.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.87,15.65,
NF-MILK OF MAGNESIA 400MG/5ML ORAL SOLUT,3201149,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-VIVELLE-DOT TRANSDERM PATCH 0.1MG/24H,3201151,CDM,250,RC,,,outpatient,,,35.24,26.43,,28.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.18,28.19,
NF-TRILIPIX CAP DR 45MG,3201152,CDM,250,RC,,,outpatient,,,7.06,5.3,,5.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.84,5.65,
NF-PREMPRO ORAL TABLET 0.625MG-2.5MG,3201153,CDM,250,RC,,,outpatient,,,13.4,10.05,,10.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.39,10.72,
NF-NEXIUM CAP DR 40MG,3201156,CDM,250,RC,,,outpatient,,,35.14,26.36,,28.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.14,28.11,
NF-NASCOBAL NASAL SPRAY 500MCG/0.1ML,3201157,CDM,250,RC,,,outpatient,,,929.61,697.21,,743.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,374.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,464.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,511.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,374.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,697.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,374.08,743.69,
NF-BACMIN ORAL TABLET,3201158,CDM,250,RC,,,outpatient,,,1.35,1.01,,1.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.08,
NF-OMEPRAZOLE CAP DR 20MG,3201159,CDM,250,RC,,,outpatient,,,19.68,14.76,,15.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.92,15.74,
NF-CIMETIDINE 400MG ORAL TABLET,3201160,CDM,637,RC,,,outpatient,,,5.67,4.25,,4.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.28,4.54,
NF-DIOVAN HCT 12.5MG-80MG ORAL TABLET,3201161,CDM,637,RC,,,outpatient,,,12.52,9.39,,10.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.04,10.02,
NF-FOSAMAX 70MG ORAL TABLET,3201162,CDM,637,RC,,,outpatient,,,127.28,95.46,,101.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.22,101.82,
NF-RAZADYNE 8MG ORAL TABLET,3201163,CDM,637,RC,,,outpatient,,,10.15,7.61,,8.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.08,8.12,
NF-ZYPREXA 2.5MG ORAL TABLET,3201164,CDM,637,RC,,,outpatient,,,58.45,43.84,,46.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.52,46.76,
"NF-DEPAKOTE 250MG ORAL TABLET, DELAYED R",3201166,CDM,637,RC,,,outpatient,,,10.75,8.06,,8.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.33,8.6,
NF-ASPIRIN ADULT LOW STRENGTH TAB EC 81M,3201167,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-FLOVENT HFA AER PWD INH ORAL/NEB 0.22,3201168,CDM,250,RC,,,outpatient,,,102.59,76.94,,82.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.28,82.07,
ASPIRIN 81mg EC,3201172,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
BACITRACIN OINT,3201173,CDM,637,RC,,,outpatient,,,12.6,9.45,,10.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.07,10.08,
BACID,3201174,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DEBROX EARWAX REMOVAL DROPS,3201175,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
ATROPINE OPTH SOL 1%,3201176,CDM,637,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
GENTAMICIN CREAM 0.1%,3201177,CDM,637,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
PHISODERM,3201178,CDM,637,RC,,,outpatient,,,10.15,7.61,,8.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.08,8.12,
NF-SINGULAIR 10MG ORAL TABLET,3201179,CDM,637,RC,,,outpatient,,,16.89,12.67,,13.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.8,13.51,
NF-VITAMIN D 50000IU ORAL CAPSULE,3201180,CDM,250,RC,,,outpatient,,,5.39,4.04,,4.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.17,4.31,
NF-GABAPENTIN 300MG ORAL TABLET,3201181,CDM,637,RC,,,outpatient,,,4.9,3.68,,3.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.97,3.92,
"NF-OMEPRAZOLE 20MG ORAL TABLET, DELAYED",3201182,CDM,250,RC,,,outpatient,,,2.3,1.73,,1.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.84,
NF-PRENATAL VITAMINS ORAL TABLET,3201184,CDM,637,RC,,,outpatient,,,1.49,1.12,,1.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.19,
NF-ASPIRIN 81MG ORAL TABLET,3201185,CDM,250,RC,,,outpatient,,,1.33,1,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.06,
AMIDATE 20 MG INJ,3201186,CDM,250,RC,,,outpatient,,,48.98,36.74,,39.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.71,39.18,
AMMONIA INHALANT,3201187,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
AMOXICILLIN 125MG/5ML,3201188,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
AMOXICILLIN 250MG/5ML,3201189,CDM,637,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
AEROCHAMBER PLUS,3201190,CDM,637,RC,,,outpatient,,,44.4,33.3,,35.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.87,35.52,
ALPHAGAN  P OPTH 0.1% 5mL,3201191,CDM,637,RC,,,outpatient,,,119,89.25,,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.89,95.2,
LIDEX E CREAM,3201192,CDM,637,RC,,,outpatient,,,15.7,11.78,,12.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.32,12.56,
GRANULEX(TBC) SPRAY,3201194,CDM,637,RC,,,outpatient,,,36.72,27.54,,29.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.78,29.38,
CEFZIL 250MG/5ML   50 ML,3201195,CDM,637,RC,,,outpatient,,,46.9,35.18,,37.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.87,37.52,
AUGMENTIN 125MG/5ML,3201196,CDM,637,RC,,,outpatient,,,78.65,58.99,,62.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.65,62.92,
BIAXIN 500 MG,3201198,CDM,637,RC,,,outpatient,,,7.25,5.44,,5.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.92,5.8,
DIPROLENE AF CREAM,3201199,CDM,637,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-CALCIUM 600/VITAMIN D ORAL CAPSULE,3201200,CDM,250,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
NF-HYDROCODONE/APAP 650MG-10MG ORAL TABL,3201201,CDM,250,RC,,,outpatient,,,6.45,4.84,,5.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.6,5.16,
"NF-VERAPAMIL 240MG ORAL TABLET, EXTENDED",3201202,CDM,250,RC,,,outpatient,,,7.98,5.99,,6.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.21,6.38,
"NF-OMEPRAZOLE 20MG ORAL CAPSULE, DELAYED",3201203,CDM,250,RC,,,outpatient,,,23.46,17.6,,18.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.44,18.77,
NF-QUESTRAN 4GM/9GM ORAL POWDER FOR SUSP,3201204,CDM,250,RC,,,outpatient,,,0.46,0.35,,0.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.37,
"NF-FENTANYL 12MCG/1HR TRANSDERMAL PATCH,",3201205,CDM,250,RC,,,outpatient,,,69.43,52.07,,55.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.94,55.54,
NF-ZINC SULFATE 220MG ORAL CAPSULE,3201206,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
HIV NEEDLESTICK KIT,3201207,CDM,637,RC,,,outpatient,,,577.25,432.94,,461.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,288.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,317.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,232.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,432.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,461.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,232.29,461.8,
CYCLOBENZAPRINE SERUM,2800974,CDM,301,RC,80368,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.84,80,
COFLEX BANDAGE,3201210,CDM,637,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
TAC 5 ML,3201211,CDM,250,RC,,,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.32,108,
NAIL POLISH REMOVER,3201213,CDM,637,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
VASELINE/BABY OIL 1:1,3201214,CDM,637,RC,,,outpatient,,,4.8,3.6,,3.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.93,3.84,
X RAY PREP KIT,3201215,CDM,637,RC,,,outpatient,,,2.4,1.8,,1.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.92,
NF-AMLODIPINE BESYLATE 2.5MG ORAL TABLET,3201217,CDM,250,RC,,,outpatient,,,6.4,4.8,,5.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.58,5.12,
"NF-DEPAKOTE ER 250MG ORAL TABLET, EXTEND",3201218,CDM,637,RC,,,outpatient,,,8.68,6.51,,6.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.49,6.94,
NF-EXELON 3MG ORAL CAPSULE,3201219,CDM,637,RC,,,outpatient,,,19.17,14.38,,15.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.71,15.34,
"NF-THEOPHYLLINE ER 100MG ORAL TABLET, EX",3201220,CDM,637,RC,,,outpatient,,,1.44,1.08,,1.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.58,1.15,
"NF-NISOLDIPINE 34MG ORAL TABLET, EXTENDE",3201221,CDM,250,RC,,,outpatient,,,31.06,23.3,,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.5,24.85,
"NF-NEXIUM 40MG ORAL CAPSULE, DELAYED REL",3201222,CDM,250,RC,,,outpatient,,,27.03,20.27,,21.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.88,21.62,
NF-NOVOLOG INJECTION 100U/ML,3201223,CDM,250,RC,,,outpatient,,,54.43,40.82,,43.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.9,43.54,
NF-XENICAL CAP 120MG,3201224,CDM,250,RC,,,outpatient,,,19.51,14.63,,15.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.85,15.61,
NF-MINIPRESS CAPSULE 2MG,3201226,CDM,637,RC,,,outpatient,,,2.74,2.06,,2.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.1,2.19,
NF-SEROQUEL XR EXTENDED-RELEASE TAB 300M,3201227,CDM,250,RC,,,outpatient,,,60.34,45.26,,48.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.28,48.27,
ALLEVYN 3X3 IN 1EA,3201228,CDM,637,RC,,,outpatient,,,10.25,7.69,,8.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.12,8.2,
ALLEVYN 5X5 IN,3201229,CDM,637,RC,,,outpatient,,,13.25,9.94,,10.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.33,10.6,
ALLEVYN 8X8 IN,3201230,CDM,637,RC,,,outpatient,,,16.25,12.19,,13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.54,13,
NF-FENOFIBRATE MICRO ORAL CAPSULE 134MG,3201231,CDM,250,RC,,,outpatient,,,6.35,4.76,,5.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.56,5.08,
NF-CONCERTA EXTENDED-RELEASE TABLET 54MG,3201233,CDM,250,RC,,,outpatient,,,18.16,13.62,,14.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.31,14.53,
NF-MAALOX 225MG/5ML-200MG/5ML ORAL SUSPE,3201234,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-COZAAR 50MG ORAL TABLET,3201235,CDM,250,RC,,,outpatient,,,8.81,6.61,,7.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.55,7.05,
NF-PRADAXA CAP 75MG,3201236,CDM,250,RC,,,outpatient,,,16.18,12.14,,12.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.51,12.94,
NF-B-12 TABLET 1000MCG,3201237,CDM,637,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
NF-D-3 ORAL CAPSULE 1000IU,3201238,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-STALEVO 200 ORAL TABLET 50MG-200MG-20,3201239,CDM,637,RC,,,outpatient,,,15.42,11.57,,12.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.21,12.34,
NF-VYVANSE CAP 50MG,3201240,CDM,250,RC,,,outpatient,,,23.17,17.38,,18.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,18.54,
SOD. CHLORIDE 14.6%,3201241,CDM,250,RC,,,outpatient,,,14.28,10.71,,11.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.75,11.42,
Nitrolingual Spray,3201243,CDM,637,RC,,,outpatient,,,244.68,183.51,,195.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.46,195.74,
NF-LISINOPRIL 40MG ORAL TABLET,3201244,CDM,250,RC,,,outpatient,,,6.25,4.69,,5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,5,
NF-TRICOR ORAL TABLET 48MG,3201247,CDM,250,RC,,,outpatient,,,7.41,5.56,,5.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.98,5.93,
NF-GLIPIZIDE ER ORAL TAB ER 2.5MG,3201248,CDM,250,RC,,,outpatient,,,3.49,2.62,,2.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.4,2.79,
NSS 1/2NS 1000ML /KCL 20MEQ,3201249,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
D5 1/2NS - K 30 MEQ 1000ML,3201250,CDM,636,RC,,,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
NF-ALPRAZOLAM 1MG ORAL TABLET,3201251,CDM,250,RC,,,outpatient,,,3.45,2.59,,2.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.39,2.76,
CEA BODY FLUID,2800987,CDM,301,RC,82378,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.48,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.48,80,
NF-MULTI-BETIC DIABETES ORAL TABLET,3201253,CDM,250,RC,,,outpatient,,,0.65,0.49,,0.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.26,0.52,
Vancomycin Oral Sol.,3201255,CDM,637,RC,,,outpatient,,,119.5,89.63,,95.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.09,95.6,
NF-DURAGESIC TD PATCH ER 12MCG/1HR,3201256,CDM,250,RC,,,outpatient,,,65.16,48.87,,52.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.22,52.13,
NF-TIZANIDINE 4MG ORAL TABLET,3201257,CDM,250,RC,,,outpatient,,,8.88,6.66,,7.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.57,7.1,
NF-LISINOPRIL-HYDROCHLOROTHIAZIDE 20MG-1,3201258,CDM,250,RC,,,outpatient,,,5.35,4.01,,4.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.15,4.28,
NF-HYDROCODONE BITART/ACET 325MG-10MG OR,3201259,CDM,250,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
NF-LEVOTHYROXINE 0.125MG ORAL TABLET,3201260,CDM,250,RC,,,outpatient,,,1.74,1.31,,1.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.39,
NF-LOVAZA LIQ CAP 1GM,3201261,CDM,250,RC,,,outpatient,,,5.45,4.09,,4.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,4.36,
VIVELLE DOT 0.025MG PER BOX OF 8,3201263,CDM,637,RC,,,outpatient,,,76.15,57.11,,60.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.64,60.92,
FENTANYL TRANSDERMAL 12MCG/HR,3201264,CDM,637,RC,,,outpatient,,,71.55,53.66,,57.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.79,57.24,
LYSOZYME,2800994,CDM,301,RC,85549,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.37,80,
"NF-MS CONTIN 30MG ORAL TABLET, EXTENDED",3201268,CDM,250,RC,,,outpatient,,,15.15,11.36,,12.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.1,12.12,
NF-HCTZ/TRIAMTERENE 25MG-37.5MG ORAL CAP,3201269,CDM,250,RC,,,outpatient,,,1.25,0.94,,1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.5,1,
FACTOR VIII ACTIVITY,2801016,CDM,302,RC,85240,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,80,
Dopram 400mg/20 ml,3201271,CDM,636,RC,,,both,,,186.5,139.88,,149.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.05,186.5,
NF-METOPROLOL 100MG ORAL TABLET,3201272,CDM,637,RC,,,outpatient,,,4.04,3.03,,3.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.63,3.23,
"NF-OMEPRAZOLE 20MG ORAL TABLET, DELAYED",3201273,CDM,250,RC,,,outpatient,,,2.54,1.91,,2.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.03,
"NF-THEOPHYLLINE 300MG ORAL CAPSULE, EXTE",3201274,CDM,250,RC,,,outpatient,,,6.11,4.58,,4.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.46,4.89,
ALDACTAZIDE 25/25,3201276,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-LISINOPRIL 40MG ORAL TABLET,3201277,CDM,637,RC,,,outpatient,,,3.33,2.5,,2.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.34,2.66,
NF-FERROUS SULFATE 65MG ORAL TABLET,3201278,CDM,637,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-DOXAZOSIN MESYLATE 8MG ORAL TABLET,3201279,CDM,637,RC,,,outpatient,,,3.49,2.62,,2.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.4,2.79,
NF-MULTIVITAMIN ORAL TABLET,3201280,CDM,250,RC,,,outpatient,,,0.47,0.35,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
"NF-FISH OIL 1000MG ORAL CAPSULE, LIQUID",3201281,CDM,250,RC,,,outpatient,,,0.62,0.47,,0.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.5,
"NF-VERAPAMIL 120MG ORAL TABLET, EXTENDED",3201282,CDM,250,RC,,,outpatient,,,3.97,2.98,,3.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.6,3.18,
Peridex Oral Rinse,3201283,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-LEUCOVORIN CALCIUM TAB 5MG,3201284,CDM,250,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
NF-ELECARE POWDER,3201285,CDM,250,RC,,,outpatient,,,0.37,0.28,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
BENICAR 5 MG TAB,3201286,CDM,637,RC,,,outpatient,,,3.05,2.29,,2.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.23,2.44,
Valproate 500mg/5ml,3201287,CDM,250,RC,,,outpatient,,,76.74,57.56,,61.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.88,61.39,
NF-ISOPTO HOMATROPINE OPHTH SOLUTION 2%,3201288,CDM,250,RC,,,outpatient,,,12.74,9.56,,10.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.13,10.19,
NF-DEXTROSE         INJ  50%,3201289,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-ASPIRIN 325MG ORAL TABLET,3201290,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-CARDIZEM 120MG ORAL TABLET,3201291,CDM,250,RC,,,outpatient,,,6.36,4.77,,5.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.56,5.09,
NF-LATUDA ORAL TABLET 80MG,3201292,CDM,250,RC,,,outpatient,,,68.33,51.25,,54.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.5,54.66,
NF-MOEXIPRIL HCL TAB 7.5MG,3201293,CDM,250,RC,,,outpatient,,,6.3,4.73,,5.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.54,5.04,
NF-MOEXIPRIL HCL TAB 15MG,3201294,CDM,250,RC,,,outpatient,,,5.38,4.04,,4.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.16,4.3,
NF-TRILEPTAL ORAL TABLET 600MG,3201295,CDM,250,RC,,,outpatient,,,30.9,23.18,,24.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.43,24.72,
NF-LAMICTAL XR PATIENT TITRATION KIT,3201297,CDM,250,RC,,,outpatient,,,29.97,22.48,,23.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.06,23.98,
NF-PENTASA CAP ER 500MG,3201298,CDM,250,RC,,,outpatient,,,6.09,4.57,,4.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.45,4.87,
NF-TIMOPTIC-XE OCUMETER OPHTH GEL DROP 0,3201301,CDM,250,RC,,,outpatient,,,31.01,23.26,,24.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.48,24.81,
NF-MILK OF MAGNESIA 400MG/5ML ORAL SUSPE,3201302,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
"NF-PRILOSEC 20MG ORAL CAPSULE, DELAYED R",3201303,CDM,250,RC,,,outpatient,,,17.11,12.83,,13.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.89,13.69,
NF-CARDURA 8MG ORAL TABLET,3201304,CDM,250,RC,,,outpatient,,,7.38,5.54,,5.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.97,5.9,
NF-VITAMIN B12 250MCG ORAL TABLET,3201305,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-LORCET 10/650 10MG-650MG ORAL TABLET,3201306,CDM,250,RC,,,outpatient,,,6.41,4.81,,5.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.58,5.13,
NF-CELEXA 40MG ORAL TABLET,3201307,CDM,250,RC,,,outpatient,,,18.97,14.23,,15.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.63,15.18,
"NF-PREVACID 30MG ORAL CAPSULE, DELAYED R",3201308,CDM,250,RC,,,outpatient,,,34.66,26,,27.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.95,27.73,
NF-RISPERDAL 0.5MG ORAL TABLET,3201309,CDM,250,RC,,,outpatient,,,24.65,18.49,,19.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.92,19.72,
"NF-PRILOSEC OTC 20MG ORAL TABLET, DELAYE",3201310,CDM,250,RC,,,outpatient,,,5.64,4.23,,4.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.51,
NF-EFFEXOR 75MG ORAL TABLET,3201311,CDM,250,RC,,,outpatient,,,11.58,8.69,,9.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.66,9.26,
NF-THIORIDAZINE HCL TAB 50MG,3201312,CDM,250,RC,,,outpatient,,,2.08,1.56,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.84,1.66,
NF-RELAGARD VAGINAL GEL/JELLY,3201313,CDM,250,RC,,,outpatient,,,1.87,1.4,,1.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.75,1.5,
NF-ARTIFICIAL TEARS OPHTHALMIC SOLUTION,3201314,CDM,250,RC,,,outpatient,,,1.31,0.98,,1.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.53,1.05,
NF-LORTAB 5/500 5MG-500MG ORAL TABLET,3201315,CDM,637,RC,,,outpatient,,,4.19,3.14,,3.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.69,3.35,
NF-ADCIRCA ORAL TABLET 20MG,3201316,CDM,250,RC,,,outpatient,,,98.7,74.03,,78.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.72,78.96,
NF-COUMADIN ORAL TABLET 6MG,3201317,CDM,250,RC,,,outpatient,,,6.28,4.71,,5.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.53,5.02,
"NF-TESSALON PERLES 100MG ORAL CAPSULE, L",3201318,CDM,250,RC,,,outpatient,,,1.3,0.98,,1.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.52,1.04,
NF-BUPROPION HYDROCHLORIDE 150MG ORAL TA,3201319,CDM,250,RC,,,outpatient,,,19.31,14.48,,15.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.77,15.45,
LYME TITER IGG IGM CSF,2801027,CDM,302,RC,86618,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.51,80,
NF-PENTAZOCINE HCL AND APAP TAB 25MG-650,3201321,CDM,250,RC,,,outpatient,,,5.65,4.24,,4.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.52,
NF-SLOW-MAG TABLET ER,3201322,CDM,250,RC,,,outpatient,,,0.63,0.47,,0.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.5,
NF-RENVELA ORAL TABLET 800MG,3201323,CDM,250,RC,,,outpatient,,,10.97,8.23,,8.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.41,8.78,
NF-AMMONIA SOLUTION,3201324,CDM,250,RC,,,outpatient,,,0.43,0.32,,0.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.17,0.34,
NF-DALIRESP 500MCG ORAL TABLET,3201325,CDM,250,RC,,,outpatient,,,25.53,19.15,,20.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.27,20.42,
Z PACK,3201326,CDM,637,RC,,,outpatient,,,4.52,3.39,,3.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.82,3.62,
NF-SENSIPAR ORAL TABLET 60MG,3201327,CDM,250,RC,,,outpatient,,,123.52,92.64,,98.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.7,98.82,
NF-FLUNISOLIDE SPRAY 0.025MG/ACT,3201328,CDM,250,RC,,,outpatient,,,9.77,7.33,,7.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.93,7.82,
SFMC ANTI-CCP,2801169,CDM,302,RC,86200,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.47,80,
"NF-OMEGA-3 FISH OIL 1200MG ORAL CAPSULE,",3201330,CDM,250,RC,,,outpatient,,,0.39,0.29,,0.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.31,
NF-PRADAXA 150MG ORAL CAPSULE,3201331,CDM,250,RC,,,outpatient,,,21.04,15.78,,16.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,16.83,
NF-LOVASTATIN 40MG ORAL TABLET,3201332,CDM,250,RC,,,outpatient,,,14.57,10.93,,11.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.86,11.66,
NF-DIOVAN 40MG ORAL TABLET,3201333,CDM,250,RC,,,outpatient,,,11.72,8.79,,9.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,9.38,
NF-GLIPIZIDE/METFORMIN HCL 5MG-500MG ORA,3201334,CDM,250,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
NF-BYSTOLIC 10MG ORAL TABLET,3201335,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-GABAPENTIN 300MG ORAL TABLET,3201336,CDM,250,RC,,,outpatient,,,4.9,3.68,,3.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.97,3.92,
"NF-TOVIAZ 8MG ORAL TABLET, EXTENDED RELE",3201337,CDM,250,RC,,,outpatient,,,21.34,16.01,,17.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.59,17.07,
NF-APAP/HYDROCODONE BITARTRATE 660MG-10M,3201338,CDM,250,RC,,,outpatient,,,3.67,2.75,,2.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.48,2.94,
"NF-ARICEPT ODT 5MG ORAL TABLET, DISINTEG",3201340,CDM,250,RC,,,outpatient,,,41.88,31.41,,33.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.85,33.5,
NF-METFORMIN HYDROCHLORIDE 750MG ORAL TA,3201341,CDM,250,RC,,,outpatient,,,4.43,3.32,,3.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.78,3.54,
NF-MELOXICAM 15MG ORAL TABLET,3201342,CDM,250,RC,,,outpatient,,,28.68,21.51,,22.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.54,22.94,
NF-LUPRON DEPOT IM 1 MONTH PWD FOR SUSP,3201343,CDM,250,RC,,,outpatient,,,2905.57,2179.18,,2324.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1169.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1452.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1452.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1452.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1598.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2324.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1169.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1169.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2324.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2179.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2324.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2324.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1169.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2324.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1169.2,2324.46,
NF-ZEMPLAR LIQUID CAPSULE 1MCG,3201344,CDM,250,RC,,,outpatient,,,41.49,31.12,,33.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.7,33.19,
Pravastatin Sodium 40 mg,3201345,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-TRIVEEN-PRX RNF LIQ CAP,3201346,CDM,250,RC,,,outpatient,,,6.58,4.94,,5.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.65,5.26,
SOD. PHOSPHATES INJ,3201347,CDM,250,RC,,,outpatient,,,6.11,4.58,,4.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.46,4.89,
NF-ONGLYZA TAB 5MG,3201348,CDM,250,RC,,,outpatient,,,31.54,23.66,,25.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.69,25.23,
Nutrilyte II 20 ml,3201349,CDM,637,RC,,,outpatient,,,13.32,9.99,,10.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.36,10.66,
NF-DONNATAL TABLET,3201350,CDM,250,RC,,,outpatient,,,2.71,2.03,,2.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.17,
NF-TRANXENE T-TAB TABLET 7.5MG,3201351,CDM,250,RC,,,outpatient,,,10.7,8.03,,8.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.31,8.56,
"NF-GLIPIZIDE 10MG ORAL TABLET, EXTENDED",3201353,CDM,250,RC,,,outpatient,,,2.98,2.24,,2.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.2,2.38,
NF-SEROQUEL 100MG ORAL TABLET,3201354,CDM,250,RC,,,outpatient,,,19.04,14.28,,15.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.66,15.23,
"NF-PRESERVISION LUTEIN ORAL CAPSULE, LIQ",3201356,CDM,250,RC,,,outpatient,,,1.13,0.85,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
NF-MELATONIN 3MG ORAL CAPSULE,3201357,CDM,250,RC,,,outpatient,,,0.41,0.31,,0.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.33,
"NF-ICAR-C PLUS SR ORAL CAPSULE, EXTENDED",3201358,CDM,250,RC,,,outpatient,,,2.31,1.73,,1.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.85,
"NF-OMEPRAZOLE 40MG ORAL CAPSULE, DELAYED",3201359,CDM,250,RC,,,outpatient,,,54.73,41.05,,43.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.02,43.78,
NF-FOLIC ACID 0.4MG ORAL TABLET,3201360,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
"NF-NEXIUM 40MG ORAL CAPSULE, DELAYED REL",3201361,CDM,250,RC,,,outpatient,,,45.77,34.33,,36.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.42,36.62,
NF-ESTRACE 0.5MG ORAL TABLET,3201362,CDM,250,RC,,,outpatient,,,1.78,1.34,,1.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.72,1.42,
NF-HYDROCODONE/APAP 650MG-10MG ORAL TABL,3201363,CDM,250,RC,,,outpatient,,,5.82,4.37,,4.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.34,4.66,
NF-FERATE 27MG ORAL TABLET,3201364,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-LYRICA 150MG ORAL CAPSULE,3201365,CDM,250,RC,,,outpatient,,,22.8,17.1,,18.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.17,18.24,
Chronulac 10gm/15ml,3201366,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-PRILOSEC CAP DR 40MG,3201367,CDM,250,RC,,,outpatient,,,21.98,16.49,,17.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.84,17.58,
NF-CORTEF ORAL TABLET 20MG,3201368,CDM,250,RC,,,outpatient,,,5.34,4.01,,4.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.15,4.27,
SFMC EBV TITER VIRAL CAPSID ANTIGEN IGG,2801178,CDM,302,RC,86665,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.07,80,
NF-LOTREL 5MG-10MG ORAL CAPSULE,3201370,CDM,637,RC,,,outpatient,,,8.74,6.56,,6.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.52,6.99,
NF-LISINOPRIL 5MG ORAL TABLET,3201371,CDM,637,RC,,,outpatient,,,3.56,2.67,,2.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.43,2.85,
"NF-CARDIZEM LA 240MG ORAL TABLET, EXTEND",3201372,CDM,637,RC,,,outpatient,,,9.49,7.12,,7.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.59,
"NF-PRILOSEC 20MG ORAL CAPSULE, DELAYED R",3201373,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-FERROUS SULFATE 325MG ORAL TABLET,3201374,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-LACTULOSE 10GM/15ML ORAL SOLUTION,3201375,CDM,250,RC,,,outpatient,,,0.23,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-MOBIC 15MG ORAL TABLET,3201376,CDM,250,RC,,,outpatient,,,36.11,27.08,,28.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.53,28.89,
NF-EXFORGE 10MG-160MG ORAL TABLET,3201377,CDM,250,RC,,,outpatient,,,16.01,12.01,,12.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.81,
"NF-VITAMIN D CAPSULE 50,000IU",3201378,CDM,250,RC,,,outpatient,,,0.74,0.56,,0.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.3,0.59,
NF-FERROUS SULFATE 325MG ORAL TABLET,3201379,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
NF-CHLOROTHIAZIDE 250MG ORAL TABLET,3201380,CDM,250,RC,,,outpatient,,,0.55,0.41,,0.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.22,0.44,
NF-CHLORTHALIDONE TAB 50MG,3201381,CDM,250,RC,,,outpatient,,,2.26,1.7,,1.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.81,
NF-TRACLEER TAB 125MG,3201382,CDM,250,RC,,,outpatient,,,434.01,325.51,,347.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,174.65,347.21,
NF-EXFORGE ORAL TABLET 10MG-160MG,3201383,CDM,250,RC,,,outpatient,,,18.37,13.78,,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.39,14.7,
NF-EXFORGE ORAL TABLET 5MG-160MG,3201384,CDM,250,RC,,,outpatient,,,16.2,12.15,,12.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.52,12.96,
NF-NORCO TAB 325MG-10MG,3201385,CDM,250,RC,,,outpatient,,,3.45,2.59,,2.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.39,2.76,
NF-VENLAFAXINE 75MG ORAL TABLET,3201386,CDM,637,RC,,,outpatient,,,12.83,9.62,,10.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,10.26,
NF-DOCUSATE SODIUM/SENNOSIDE 50MG-8.6MG,3201387,CDM,250,RC,,,outpatient,,,1.17,0.88,,0.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.47,0.94,
NF-ASPIR-LOW 81MG ORAL TABLET,3201388,CDM,637,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-SUCRALFATE 1GM ORAL TABLET,3201389,CDM,637,RC,,,outpatient,,,2.78,2.09,,2.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,2.22,
NF-ARANESP 0.1MG/0.5ML INJECTION SOLUTIO,3201390,CDM,250,RC,,,outpatient,,,5315.57,3986.68,,4252.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2138.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2657.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2657.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2657.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2657.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2923.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4252.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3986.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3986.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3986.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3986.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2138.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2138.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4252.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3986.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4252.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4252.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2138.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4252.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2138.99,4252.46,
"NF-VITAMIN D3 2000IU ORAL CAPSULE, LIQUI",3201391,CDM,637,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
"NF-LOVAZA 1GM ORAL CAPSULE, LIQUID FILLE",3201392,CDM,250,RC,,,outpatient,,,9.36,7.02,,7.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.77,7.49,
NF-LEVOCETIRIZINE DIHYDROCHLORIDE 5MG OR,3201393,CDM,250,RC,,,outpatient,,,11.38,8.54,,9.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.58,9.1,
NF-DIOVAN HCT 25MG-320MG ORAL TABLET,3201394,CDM,637,RC,,,outpatient,,,23.12,17.34,,18.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.3,18.5,
NF-CITRACAL + D 315MG-200IU ORAL TABLET,3201395,CDM,250,RC,,,outpatient,,,0.53,0.4,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
T B SKIN TEST 0.5ML,3201396,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
TYLENOL SUPP. 80 MG,3201397,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-ALBUTEROL  SOL 0.083%,3201398,CDM,250,RC,,,outpatient,,,1.64,1.23,,1.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.66,1.31,
NF-STARLIX TAB 120MG,3201399,CDM,250,RC,,,outpatient,,,4.41,3.31,,3.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.77,3.53,
NF-NUEDEXTA CAP 20MG-10MG,3201400,CDM,250,RC,,,outpatient,,,39.03,29.27,,31.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.71,31.22,
NF-PRAZOSIN HCL CAP 1MG,3201401,CDM,250,RC,,,outpatient,,,2.05,1.54,,1.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.64,
NF-TRILIPIX CAP DR 135MG,3201403,CDM,250,RC,,,outpatient,,,22.01,16.51,,17.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.86,17.61,
NF-DRY EYE RELIEF OPHTH SOLUTION,3201404,CDM,250,RC,,,outpatient,,,1.76,1.32,,1.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.71,1.41,
NF-TOPICORT OINT 0.05%,3201405,CDM,250,RC,,,outpatient,,,16.15,12.11,,12.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.5,12.92,
BMX SOLUTION 5ML,3201406,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-MOTRIN CHILDREN'S SUSPENSION 100MG/5M,3201407,CDM,637,RC,,,outpatient,,,0.31,0.23,,0.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.25,
NF-DEMEROL HCL INJ SOLN 50MG/1ML,3201408,CDM,637,RC,,,outpatient,,,3.57,2.68,,2.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.44,2.86,
NF-LORTAB 10/500 TABLET,3201409,CDM,637,RC,,,outpatient,,,7.82,5.87,,6.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.15,6.26,
"NF-SEROQUEL XR 150MG ORAL TABLET, EXTEND",3201412,CDM,637,RC,,,outpatient,,,41.81,31.36,,33.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.82,33.45,
NF-SEROQUEL 100MG ORAL TABLET,3201413,CDM,250,RC,,,outpatient,,,23.94,17.96,,19.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.63,19.15,
NF-ASPIRIN ADULT LOW STRENGTH 81MG ORAL,3201414,CDM,637,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-HYZAAR ORAL TABLET 100MG-12.5MG,3201415,CDM,250,RC,,,outpatient,,,15.23,11.42,,12.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.13,12.18,
NF-CALMOSEPTINE OINTMENT,3201416,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-TRILEPTAL ORAL TABLET 150MG,3201417,CDM,250,RC,,,outpatient,,,9.21,6.91,,7.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.71,7.37,
NF-TWOCAL HN LIQUID,3201418,CDM,637,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-TWOCAL HN LIQUID,3201419,CDM,637,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-KLONOPIN TABLET 1MG,3201420,CDM,250,RC,,,outpatient,,,6.47,4.85,,5.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.6,5.18,
NF-APIDRA INJ SOLN 100U/1ML,3201421,CDM,250,RC,,,outpatient,,,41.31,30.98,,33.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.62,33.05,
SFMC FACTOR VIII ACTIVITY,2801252,CDM,302,RC,85240,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,80,
NF-BACLOFEN 20MG ORAL TABLET,3201423,CDM,250,RC,,,outpatient,,,7.71,5.78,,6.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.1,6.17,
"NF-OXYCONTIN 60MG ORAL TABLET, EXTENDED",3201424,CDM,250,RC,,,outpatient,,,49.83,37.37,,39.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.05,39.86,
NF-XANAX 2MG ORAL TABLET,3201425,CDM,250,RC,,,outpatient,,,18.69,14.02,,14.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.52,14.95,
NF-HYDROCODONE BITART/ACET 650MG-10MG OR,3201426,CDM,250,RC,,,outpatient,,,2.22,1.67,,1.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.89,1.78,
NF-ASPIRIN 81MG ORAL TABLET,3201427,CDM,250,RC,,,outpatient,,,0.61,0.46,,0.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.49,
NF-FLUTAMIDE CAP 125MG,3201428,CDM,250,RC,,,outpatient,,,7.7,5.78,,6.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.1,6.16,
NF-RISPERDAL ORAL TABLET 0.5MG,3201429,CDM,250,RC,,,outpatient,,,19.65,14.74,,15.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.91,15.72,
NF-FLUTAMIDE CAP 125MG,3201430,CDM,250,RC,,,outpatient,,,7.7,5.78,,6.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.1,6.16,
NF-ABACAVIR SULFATE TAB 300MG,3201431,CDM,250,RC,,,outpatient,,,38.81,29.11,,31.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.62,31.05,
NF-EPIVIR HBV TAB 100MG,3201432,CDM,250,RC,,,outpatient,,,53.59,40.19,,42.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.56,42.87,
NF-NORVIR CAPSULE 100MG,3201433,CDM,250,RC,,,outpatient,,,48.82,36.62,,39.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.65,39.06,
NF-PREZISTA ORAL TABLET 400MG,3201434,CDM,250,RC,,,outpatient,,,68.35,51.26,,54.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.5,54.68,
NF-MIDODRINE HCL ORAL TABLET 2.5MG,3201435,CDM,250,RC,,,outpatient,,,4.44,3.33,,3.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,3.55,
NF-DUREZOL OPHTH EMUL 0.05%,3201436,CDM,250,RC,,,outpatient,,,87.16,65.37,,69.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.07,69.73,
NF-LITHIUM CARB EXTENDED-RELEASE TABLET,3201437,CDM,250,RC,,,outpatient,,,3.44,2.58,,2.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.38,2.75,
NF-KENALOG IN ORABASE PASTE 0.1%,3201438,CDM,250,RC,,,outpatient,,,16.27,12.2,,13.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.55,13.02,
NF-CHLORTHALIDONE TAB 25MG,3201439,CDM,250,RC,,,outpatient,,,1.17,0.88,,0.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.47,0.94,
NF-CHLORTHALIDONE TAB 25MG,3201440,CDM,250,RC,,,outpatient,,,1.34,1.01,,1.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.07,
NF-TICLOPIDINE HC TAB  250MG,3201441,CDM,250,RC,,,outpatient,,,7.12,5.34,,5.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,5.7,
NF-EDARBI ORAL TABLET 40MG,3201442,CDM,250,RC,,,outpatient,,,11.99,8.99,,9.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.82,9.59,
NF-ZYVOX TAB 600MG,3201443,CDM,250,RC,,,outpatient,,,432.62,324.47,,346.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,216.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,174.09,346.1,
NF-QVAR INH/NEB AEROSOL LIQUID 0.08MG/1A,3201445,CDM,250,RC,,,outpatient,,,45.62,34.22,,36.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.36,36.5,
NF-TAMBOCOR ORAL TABLET 100MG,3201446,CDM,250,RC,,,outpatient,,,15.16,11.37,,12.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.1,12.13,
NF-TRILIPIX CAP DR 135MG,3201447,CDM,250,RC,,,outpatient,,,22.45,16.84,,17.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.03,17.96,
NF-EDARBI ORAL TABLET 80MG,3201448,CDM,250,RC,,,outpatient,,,11.99,8.99,,9.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.82,9.59,
NF-MIDODRINE HCL ORAL TABLET 10MG,3201449,CDM,250,RC,,,outpatient,,,17.89,13.42,,14.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.2,14.31,
NF-RESTASIS OPHTH EMULSION 0.05%,3201450,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-TOVIAZ ORAL EXTENDED RELEASE TABLET 8,3201451,CDM,250,RC,,,outpatient,,,20.83,15.62,,16.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.38,16.66,
NF-ACTONEL TAB 5MG,3201452,CDM,250,RC,,,outpatient,,,17.49,13.12,,13.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.04,13.99,
NF-BONIVA ORAL TABLET 150MG,3201453,CDM,250,RC,,,outpatient,,,570.96,428.22,,456.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,229.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,285.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,314.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,229.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,456.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,229.75,456.77,
NF-MOEXIPRIL HCL TAB 15MG,3201454,CDM,250,RC,,,outpatient,,,11.01,8.26,,8.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.81,
NF-XARELTO ORAL TABLET 10MG,3201455,CDM,250,RC,,,outpatient,,,32.37,24.28,,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.03,25.9,
NF-PRIMIDONE ORAL TABLET 250MG,3201456,CDM,250,RC,,,outpatient,,,3.69,2.77,,2.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.48,2.95,
XARELTO  10 mg,3201457,CDM,637,RC,,,outpatient,,,8.92,6.69,,7.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.59,7.14,
Actonel 5 mg,3201458,CDM,637,RC,,,outpatient,,,5.55,4.16,,4.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.23,4.44,
Primidone 250 mg,3201459,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-TRADJENTA ORAL TABLET 5MG,3201460,CDM,250,RC,,,outpatient,,,31.55,23.66,,25.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.7,25.24,
NF-SOLU MEDROL INJECTION PWD FOR SOLN 12,3201461,CDM,637,RC,,,outpatient,,,26.98,20.24,,21.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.58,
NF-ADVAIR HFA AER INH 115MCG-30.45MCG/1,3201463,CDM,250,RC,,,outpatient,,,89.86,67.4,,71.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.16,71.89,
BB BLOOD PROCESSING PACKED CELLS,3000030,CDM,390,RC,P9016BL,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-PATADAY OPHTH SOLN 0.2%,3201466,CDM,250,RC,,,outpatient,,,204.68,153.51,,163.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.36,163.74,
NF-DULERA INH AER PWD 5MCG-200MCG/ACT,3201467,CDM,250,RC,,,outpatient,,,71.5,53.63,,57.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.77,57.2,
D 5 W   50 ML,3201468,CDM,636,RC,,,both,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,16.5,
NF-CREON CAP DR,3201474,CDM,250,RC,,,outpatient,,,4.39,3.29,,3.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.77,3.51,
NF-TOVIAZ TAB ER 4MG,3201475,CDM,250,RC,,,outpatient,,,22.08,16.56,,17.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.88,17.66,
DAKIN'S SOLUTION 0.25%,3201477,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NovoLog Mix 70/30 1 Unit,3201478,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-THALOMID CAP 200MG,3201480,CDM,250,RC,,,outpatient,,,1245.95,934.46,,996.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,501.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,622.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,622.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,622.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,622.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,685.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,501.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,501.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,996.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,934.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,996.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,501.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,996.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,501.37,996.76,
"NF-VITAMIN A CAPSULE 10,000IU",3201481,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-URISPAS TABLET 100MG,3201482,CDM,250,RC,,,outpatient,,,7.7,5.78,,6.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.1,6.16,
NF-GLUCOSAMINE CHONDROITIN TABLET,3201483,CDM,250,RC,,,outpatient,,,1.04,0.78,,0.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.42,0.83,
BB BLOOD PROCESSING PTP,3000031,CDM,390,RC,P9034,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,746.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,746.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,746.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,500.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,746.15,
NF-LICE TREATMENT SHAMPOO,3201486,CDM,250,RC,,,outpatient,,,0.33,0.25,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
Cardizem 125mg/25ml,3201487,CDM,250,RC,,,outpatient,,,41.25,30.94,,33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.6,33,
KANGAROO SCREW SPIKE SET,3201488,CDM,637,RC,,,outpatient,,,24.75,18.56,,19.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.96,19.8,
KANGAROO 500ML FLUSH BAG,3201489,CDM,637,RC,,,outpatient,,,24.75,18.56,,19.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.96,19.8,
NF-DIVALPROEX SODIUM ORAL TAB DR 250MG,3201490,CDM,250,RC,,,outpatient,,,6.52,4.89,,5.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.22,
NF-ONGLYZA TAB 2.5MG,3201491,CDM,250,RC,,,outpatient,,,33.12,24.84,,26.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.33,26.5,
NF-PREMPRO ORAL TABLET 0.3MG-1.5MG,3201492,CDM,250,RC,,,outpatient,,,12.11,9.08,,9.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.87,9.69,
NF-DEXILANT CAP DR 60MG,3201493,CDM,250,RC,,,outpatient,,,16.21,12.16,,12.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.52,12.97,
NF-HYDROCORTISONE 1% CREAM,3201494,CDM,637,RC,,,outpatient,,,0.72,0.54,,0.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.29,0.58,
NF-EDARBYCLOR ORAL TABLET 40MG-12.5MG,3201495,CDM,250,RC,,,outpatient,,,12.3,9.23,,9.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.95,9.84,
NF-DEXILANT CAP DR 30MG,3201496,CDM,250,RC,,,outpatient,,,21.04,15.78,,16.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,16.83,
NF-NATEGLINIDE ORAL TABLET 120MG,3201497,CDM,250,RC,,,outpatient,,,6.39,4.79,,5.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.57,5.11,
NF-SPORANOX CAP 100MG,3201499,CDM,637,RC,,,outpatient,,,64.72,48.54,,51.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.04,51.78,
NF-AVELOX ORAL TABLET 400MG,3201500,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-VYVANSE CAP 20MG,3201501,CDM,250,RC,,,outpatient,,,14.92,11.19,,11.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,11.94,
NF-ELIDEL CRM 1%,3201502,CDM,250,RC,,,outpatient,,,24.27,18.2,,19.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.77,19.42,
NF-NIFEREX-150 FORTE CAPSULE,3201503,CDM,250,RC,,,outpatient,,,0.74,0.56,,0.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.3,0.59,
NF-ADVAIR HFA AER INH 115MCG-30.45MCG/1A,3201504,CDM,250,RC,,,outpatient,,,77.08,57.81,,61.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.02,61.66,
COMBIVENT RESPIMAT,3201505,CDM,637,RC,,,outpatient,,,257.1,192.83,,205.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,103.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,103.46,205.68,
NF-NATEGLINIDE ORAL TABLET 120MG,3201506,CDM,250,RC,,,outpatient,,,6.39,4.79,,5.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.57,5.11,
NF-ELMIRON CAP 100MG,3201507,CDM,250,RC,,,outpatient,,,16.06,12.05,,12.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.46,12.85,
NF-LATUDA TAB 40MG,3201508,CDM,250,RC,,,outpatient,,,74.46,55.85,,59.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.96,59.57,
NF-UNIVASC TAB 7.5MG,3201509,CDM,250,RC,,,outpatient,,,10.51,7.88,,8.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.41,
NF-LATUDA TAB 80MG,3201511,CDM,250,RC,,,outpatient,,,74.46,55.85,,59.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.96,59.57,
LIPOSYN 20% 250 ML,3201512,CDM,250,RC,,,outpatient,,,126.5,94.88,,101.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.9,101.2,
NF-AZASITE OPHTH SOLN 1%,3201513,CDM,250,RC,,,outpatient,,,161.25,120.94,,129,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.89,129,
NF-DULERA INH AER PWD 5MCG-100MCG/ACT,3201514,CDM,250,RC,,,outpatient,,,71.5,53.63,,57.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.77,57.2,
DEXTROSE 70% 500ML,3201515,CDM,636,RC,,,both,,,27.56,20.67,,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.09,27.56,
VIVELLE DOT O.1MG (BOX OF 8),3201517,CDM,637,RC,,,outpatient,,,81.51,61.13,,65.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.8,65.21,
HYZAAR 100/12.5,3201518,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-BIOTIN ORAL TABLET 5MG,3201519,CDM,250,RC,,,outpatient,,,0.45,0.34,,0.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.18,0.36,
NF-NITROGLYCERIN ORAL TABLET SL 0.4MG,3201520,CDM,250,RC,,,outpatient,,,2.87,2.15,,2.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.15,2.3,
LISINOPRIL/HCTZ 20/25,3201522,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-DOXEPIN HCL CAP 10MG,3201523,CDM,250,RC,,,outpatient,,,1.17,0.88,,0.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.47,0.94,
NF-AZOR ORAL TABLET 10MG-40MG,3201524,CDM,250,RC,,,outpatient,,,21.84,16.38,,17.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.79,17.47,
NF-NORCO TAB 325MG-5MG,3201525,CDM,637,RC,,,outpatient,,,5.78,4.34,,4.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.33,4.62,
BB BLOOD PROCESSING FFP,3000032,CDM,390,RC,P9017,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,136.75,
NF-INVEGA ORAL EXTENDED RELEASE TABLET 3,3201527,CDM,250,RC,,,outpatient,,,81.34,61.01,,65.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.73,65.07,
NF-PHENOBARBITAL ORAL TABLET 68.4MG,3201528,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-ANDROGEL GEL 1%,3201529,CDM,250,RC,,,outpatient,,,8.78,6.59,,7.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.53,7.02,
Triamcinolone Dental Paste,3201530,CDM,637,RC,,,outpatient,,,22.74,17.06,,18.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.15,18.19,
NF-METHOTREXATE ORAL TABLET 2.5MG,3201531,CDM,250,RC,,,outpatient,,,4.04,3.03,,3.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.63,3.23,
NF-ZYRTEC ORAL CHEWABLE TABLET 10MG,3201532,CDM,250,RC,,,outpatient,,,17.27,12.95,,13.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.95,13.82,
NF-QVAR INH/NEB AER LIQ 0.04MG/1 ACTUATI,3201533,CDM,250,RC,,,outpatient,,,42.07,31.55,,33.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.93,33.66,
NF-ULORIC TAB 40MG,3201534,CDM,250,RC,,,outpatient,,,26.16,19.62,,20.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.53,20.93,
"NF-OCTREOTIDE ACETATE INJ SOLN 1,000MCG/",3201535,CDM,250,RC,,,outpatient,,,867.62,650.72,,694.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,433.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,433.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,433.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,433.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,477.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,349.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,349.13,694.1,
NF-POTASSIUM GLUCONATE TABLET 550MG,3201536,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-OCTREOTIDE ACETATE INJ SOLN 100MCG/1M,3201537,CDM,250,RC,,,outpatient,,,23.98,17.99,,19.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.65,19.18,
NF-SYSTANE LUBRICANT EYE DROPS 0.4%-0.3%,3201539,CDM,637,RC,,,outpatient,,,6.43,4.82,,5.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,5.14,
NF-SYSTANE LUBRICANT EYE DROPS 0.4%-0.3%,3201540,CDM,250,RC,,,outpatient,,,6.43,4.82,,5.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,5.14,
NF-CEFDINIR CAP 300MG,3201541,CDM,250,RC,,,outpatient,,,25.29,18.97,,20.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.18,20.23,
NF-KERAFOAM 42 FOAM 42%,3201542,CDM,250,RC,,,outpatient,,,10.84,8.13,,8.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.36,8.67,
NF-BIOFREEZE GEL,3201543,CDM,250,RC,,,outpatient,,,0.58,0.44,,0.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.46,
NF-MEPHYTON ORAL TABLET 5MG,3201544,CDM,250,RC,,,outpatient,,,10.25,7.69,,8.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.12,8.2,
NF-POTASSIUM PHOSPHATE PWD,3201545,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-MIDODRINE HCL TAB 2.5MG,3201546,CDM,250,RC,,,outpatient,,,4.44,3.33,,3.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,3.55,
NF-TALACEN TABLET,3201547,CDM,250,RC,,,outpatient,,,9.85,7.39,,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.96,7.88,
NF-B6-FOLIC ACID ORAL CAPSULE,3201548,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-FEMARA TABLET 2.5MG,3201549,CDM,250,RC,,,outpatient,,,74.55,55.91,,59.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30,59.64,
VIT. D 5000 IU,3201550,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-ENBREL SUBCUTANEOUS SOLUTION 50MG/1ML,3201551,CDM,250,RC,,,outpatient,,,2342.52,1756.89,,1874.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,942.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1171.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1171.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1171.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1171.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1288.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1874.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,942.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1874.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1756.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1874.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1874.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,942.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1874.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,942.63,1874.02,
NF-VITAMIN B-6 ORAL TABLET 100MG,3201552,CDM,250,RC,,,outpatient,,,1.23,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
NF-IBANDRONATE SODIUM TAB 150MG,3201553,CDM,250,RC,,,outpatient,,,575.05,431.29,,460.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,231.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,287.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,287.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,287.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,287.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,316.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,231.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,460.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,231.4,460.04,
NF-ACIDOPHILUS PROBIOTIC BLEND ORAL CAP,3201554,CDM,250,RC,,,outpatient,,,0.15,0.11,,0.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.12,
NF-GAS RELIEF LIQUID FILLED CAP 125MG,3201555,CDM,637,RC,,,outpatient,,,0.34,0.26,,0.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.27,
NF-OMEGA-3 ORAL LIQUID FILLED CAPSULE,3201556,CDM,637,RC,,,outpatient,,,0.69,0.52,,0.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.28,0.55,
NF-OMEPRAZOLE CAP DR 20MG,3201557,CDM,637,RC,,,outpatient,,,19.68,14.76,,15.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.92,15.74,
NF-TRILIPIX CAP DR 135MG,3201558,CDM,637,RC,,,outpatient,,,22.45,16.84,,17.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.03,17.96,
NF-CALCIUM 600 TABLET 600MG,3201561,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-ROXANOL SOLN 20MG/1ML,3201562,CDM,250,RC,,,outpatient,,,2.47,1.85,,1.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.99,1.98,
MORPHINE ORAL SOLUTION 20MG/5ML,3201563,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
Relistor,3201564,CDM,250,RC,,,outpatient,,,69.18,51.89,,55.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.84,55.34,
NF-NEXIUM CAP DR 40MG,3201565,CDM,250,RC,,,outpatient,,,28.77,21.58,,23.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.58,23.02,
NF-CREON ORAL DELAYED RELEASE CAPSULE,3201566,CDM,250,RC,,,outpatient,,,4.34,3.26,,3.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.75,3.47,
NF-SAW PALMETTO CAPSULE 160MG,3201567,CDM,250,RC,,,outpatient,,,0.57,0.43,,0.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.46,
NF-PERMETHRIN CREAM 5%,3201568,CDM,250,RC,,,outpatient,,,4.73,3.55,,3.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.9,3.78,
NF-FENOFIBRATE MICRO ORAL CAPSULE 200MG,3201569,CDM,250,RC,,,outpatient,,,11.66,8.75,,9.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.69,9.33,
NF-PHENOBARBITAL TAB 100MG,3201570,CDM,250,RC,,,outpatient,,,0.59,0.44,,0.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.24,0.47,
NF-LUNESTA ORAL TABLET 3MG,3201571,CDM,250,RC,,,outpatient,,,16.45,12.34,,13.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,13.16,
ACETYLCYSTEINE 20% SOLN.,3201572,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-BETHANECHOL CHLORIDE ORAL TABLET 50MG,3201573,CDM,250,RC,,,outpatient,,,10.56,7.92,,8.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.25,8.45,
NF-KEPPRA XR TAB ER 500MG,3201574,CDM,250,RC,,,outpatient,,,23.09,17.32,,18.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.29,18.47,
NF-SEROQUEL TAB 300MG,3201575,CDM,250,RC,,,outpatient,,,73.22,54.92,,58.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.46,58.58,
NF-INVOKANA ORAL TABLET 100MG,3201576,CDM,250,RC,,,outpatient,,,38.94,29.21,,31.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.67,31.15,
NF-LINACLOTIDE CAP 290MCG,3201577,CDM,250,RC,,,outpatient,,,31.52,23.64,,25.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.68,25.22,
NF-THIAMINE HCL TABLET 250MG,3201578,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-UROGESIC-BLUE ORAL TABLET,3201579,CDM,250,RC,,,outpatient,,,6.81,5.11,,5.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.74,5.45,
NF-ZEMPLAR INJECTION 0.005MG/ML,3201580,CDM,250,RC,,,outpatient,,,67.27,50.45,,53.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.07,53.82,
NF-SENSIPAR ORAL TABLET 30MG,3201581,CDM,250,RC,,,outpatient,,,45.4,34.05,,36.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.27,36.32,
NF-LUVOX CR CAP ER 100MG,3201583,CDM,250,RC,,,outpatient,,,48.15,36.11,,38.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.38,38.52,
NF-NOVOLOG MIX 70/30 SUBQ SUSP 70U-30U/1,3201584,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-CHLORPROMAZINE HCL TAB 10MG,3201585,CDM,250,RC,,,outpatient,,,3.29,2.47,,2.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.32,2.63,
NF-CRANBERRY ORAL TABLET 400MG,3201586,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-ABILIFY ORAL TABLET 2MG,3201589,CDM,250,RC,,,outpatient,,,99.04,74.28,,79.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.85,79.23,
NF-ACTONEL ORAL TABLET 150MG,3201590,CDM,250,RC,,,outpatient,,,585.08,438.81,,468.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,235.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,292.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,321.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,235.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,235.44,468.06,
NF-LEFLUNOMIDE ORAL TABLET 20MG,3201591,CDM,250,RC,,,outpatient,,,60.76,45.57,,48.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.45,48.61,
NF-B-COMPLEX TABLET,3201592,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-TRILEPTAL SUSPENSION 300MG/5ML,3201593,CDM,250,RC,,,outpatient,,,1.32,0.99,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.53,1.06,
NF-CEVIMELINE HCL CAP 30MG,3201594,CDM,250,RC,,,outpatient,,,15.63,11.72,,12.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.29,12.5,
NF-DERMA-GEL SEMI-OCCLUSIVE,3201595,CDM,250,RC,,,outpatient,,,12.6,9.45,,10.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.07,10.08,
NF-SINGULAIR CHEW TAB 4MG,3201596,CDM,250,RC,,,outpatient,,,23.26,17.45,,18.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.36,18.61,
NF-VALPROIC ACID LIQ CAP 250MG,3201597,CDM,250,RC,,,outpatient,,,3.04,2.28,,2.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.22,2.43,
BENTYL INJ 20 MG,3200077,CDM,636,RC,J0500,HCPCS,both,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,100,
NF-MENOMUNE-A/C/Y/W-1 POWDER FOR INJ 0.0,3201600,CDM,250,RC,,,outpatient,,,517.67,388.25,,414.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,208.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,258.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,258.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,258.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,208.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,208.31,414.14,
ZOFRAN INJ 40MG/20mL INJ,3200970,CDM,636,RC,J2405,HCPCS,both,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,100,
NF-CREON CAP DR,3201602,CDM,250,RC,,,outpatient,,,16.54,12.41,,13.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.66,13.23,
Haemophilus b Vaccine,3201603,CDM,250,RC,,,outpatient,,,246.85,185.14,,197.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.33,197.48,
NF-SYSTANE OPHTHALMIC SOLUTION 0.4%-0.3%,3201604,CDM,250,RC,,,outpatient,,,1.89,1.42,,1.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.76,1.51,
NF-METHOTREXATE SODIUM INJ PWD FOR SOLN,3201605,CDM,250,RC,,,outpatient,,,282.38,211.79,,225.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,141.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,113.63,225.9,
NF-FOLIC ACID ORAL TABLET 0.4MG,3201606,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-FOSAMAX ORAL TABLET 10MG,3201607,CDM,250,RC,,,outpatient,,,12.35,9.26,,9.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.97,9.88,
METHOTREXATE 50MG/2ML,3201608,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-FLURAZEPAM HCL CAP 15MG,3201609,CDM,250,RC,,,outpatient,,,2.04,1.53,,1.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.63,
NF-ATENOLOL/CHLORTHALIDONE TAB 100MG-25M,3201610,CDM,250,RC,,,outpatient,,,0.91,0.68,,0.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.37,0.73,
NF-BICALUTAMIDE ORAL TABLET 50MG,3201611,CDM,250,RC,,,outpatient,,,60.92,45.69,,48.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.51,48.74,
PLAVIX 300 MG,3201612,CDM,637,RC,,,outpatient,,,19.2,14.4,,15.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.73,15.36,
XARELTO 15 MG,3201613,CDM,637,RC,,,outpatient,,,9.46,7.1,,7.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.81,7.57,
NF-CELECOXIB CAP 100MG,3201614,CDM,250,RC,,,outpatient,,,14.17,10.63,,11.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.7,11.34,
NF-LATUDA TAB 20MG,3201615,CDM,250,RC,,,outpatient,,,81.83,61.37,,65.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.93,65.46,
NF-NAMENDA XR CAP ER 7MG,3201616,CDM,250,RC,,,outpatient,,,37.32,27.99,,29.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.02,29.86,
NF-MAGNESIUM ACETATE CRYSTAL,3201618,CDM,250,RC,,,outpatient,,,0.28,0.21,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-TRILEPTAL ORAL TABLET 300MG,3201619,CDM,250,RC,,,outpatient,,,15.99,11.99,,12.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,12.79,
Meloxicam 15 mg,3201620,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-FENOFIBRATE ORAL TABLET 54MG,3201621,CDM,250,RC,,,outpatient,,,7.65,5.74,,6.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.08,6.12,
NF-DOCUSATE SOD AND SENNA TABLET 50MG-8.,3201622,CDM,250,RC,,,outpatient,,,0.67,0.5,,0.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.27,0.54,
NF-MARINOL CAPSULE 5MG,3201623,CDM,250,RC,,,outpatient,,,54.96,41.22,,43.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.12,43.97,
NF-SIMPLE SYRUP,3201624,CDM,250,RC,,,outpatient,,,2.22,1.67,,1.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.89,1.78,
NF-TROLAMINE SALICYLATE CRM 10%,3201625,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-NORCO ORAL TABLET 325MG-10MG,3201626,CDM,250,RC,,,outpatient,,,9.7,7.28,,7.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.9,7.76,
NF-K-PHOS ORIGINAL TAB 500MG,3201627,CDM,250,RC,,,outpatient,,,0.74,0.56,,0.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.3,0.59,
NF-ZYPREXA ORAL TABLET 2.5MG,3201628,CDM,250,RC,,,outpatient,,,54.06,40.55,,43.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.75,43.25,
NF-DEPAKOTE DELAYED-RELEASE TABLET 125MG,3201629,CDM,250,RC,,,outpatient,,,1.81,1.36,,1.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.45,
NITHIODOTE,3201630,CDM,636,RC,,,both,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,375,
PR XR T-TUBE CHOLANGIOGRAM,4001127,CDM,972,RC,47544,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,570.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,570.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,570.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,100,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,100,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,570.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,160,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,100,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,140,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60,570.55,
PR XR ANKLE ARTHROGRAM,4010027,CDM,972,RC,7361526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
PR XR ESOPHOGRAM,4010051,CDM,972,RC,7422026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
SODIUM CHLORIDE TABLET 1 GM,3201634,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-VYVANSE ORAL CAPSULE 20MG,3201636,CDM,250,RC,,,outpatient,,,25.26,18.95,,20.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.16,20.21,
NF-CINNAMON ORAL CAPSULE 500MG,3201637,CDM,250,RC,,,outpatient,,,0.19,0.14,,0.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.15,
PR XR FISTULAGRAM,4010055,CDM,972,RC,7608026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-ACTOPLUS MET ORAL TABLET 850MG-15MG,3201639,CDM,250,RC,,,outpatient,,,26.46,19.85,,21.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.65,21.17,
NF-PROLENSA OPHTH SOLN 0.07%,3201640,CDM,250,RC,,,outpatient,,,473.51,355.13,,378.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,236.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,190.54,378.81,
NF-OFLOXACIN OPHTH SOLN 0.3%,3201641,CDM,250,RC,,,outpatient,,,44.81,33.61,,35.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.03,35.85,
NF-ZIKS HEMATOGEN FA LIQ CAP,3201642,CDM,250,RC,,,outpatient,,,1.33,1,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.06,
NF-OMEPRAZOLE CAP DR 20MG,3201643,CDM,250,RC,,,outpatient,,,32.64,24.48,,26.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.13,26.11,
NF-TRAZODONE HCL ORAL TABLET 150MG,3201644,CDM,250,RC,,,outpatient,,,5.44,4.08,,4.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,4.35,
NF-BUSPIRONE HCL TAB 15MG,3201645,CDM,250,RC,,,outpatient,,,7.47,5.6,,5.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.01,5.98,
NF-CLONAZEPAM ORAL TABLET 1MG,3201646,CDM,250,RC,,,outpatient,,,6.29,4.72,,5.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.53,5.03,
NF-MIDAZOLAM HCL INJ SOLN 5MG/1ML,3201647,CDM,250,RC,,,outpatient,,,5.68,4.26,,4.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.29,4.54,
NF-MIDAZOLAM HCL INJ SOLN 5MG/1ML,3201648,CDM,250,RC,,,outpatient,,,3.06,2.3,,2.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.23,2.45,
NF-LETROZOLE ORAL TABLET 2.5MG,3201649,CDM,250,RC,,,outpatient,,,67.02,50.27,,53.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.97,53.62,
NF-INVOKANA ORAL TABLET 300MG,3201650,CDM,250,RC,,,outpatient,,,38.94,29.21,,31.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.67,31.15,
NF-EPITOL TABLET 200MG,3201651,CDM,250,RC,,,outpatient,,,1.12,0.84,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
NF-ANASTROZOLE ORAL TABLET 1MG,3201652,CDM,250,RC,,,outpatient,,,49.22,36.92,,39.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.81,39.38,
MIDAZOLAM 50MG/10ML,3201653,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-NOVOLOG FLEXPEN SQ SOLN 100U/ML,3201654,CDM,250,RC,,,outpatient,,,87.48,65.61,,69.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.2,69.98,
NF-BROMOCRIPTINE MESYLATE TAB 2.5MG,3201655,CDM,250,RC,,,outpatient,,,6.78,5.09,,5.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.73,5.42,
NF-ETODOLAC CAP 200MG,3201656,CDM,250,RC,,,outpatient,,,4.74,3.56,,3.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.91,3.79,
NF-PROTONIX INJECTION 40MG,3201658,CDM,637,RC,,,outpatient,,,22.2,16.65,,17.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.93,17.76,
NF-ASACOL HD TAB DR 800MG,3201659,CDM,250,RC,,,outpatient,,,16.13,12.1,,12.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.9,
NF-NEXAVAR ORAL TABLET 200MG,3201660,CDM,250,RC,,,outpatient,,,362.25,271.69,,289.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.77,289.8,
NF-ONGLYZA TAB 5MG,3201661,CDM,250,RC,,,outpatient,,,36.4,27.3,,29.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.65,29.12,
NF-NEPRO LIQUID,3201662,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
ALPHAGAN OPTH 0.2%,3201663,CDM,637,RC,,,outpatient,,,21.75,16.31,,17.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.75,17.4,
NF-NALFON CAP 400MG,3201664,CDM,250,RC,,,outpatient,,,11.84,8.88,,9.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.76,9.47,
NF-AMITIZA LIQ CAP 8MCG,3201666,CDM,250,RC,,,outpatient,,,19.28,14.46,,15.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.76,15.42,
RANITIDINE SYRUP 15MG/ML,3201667,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SINGULAIR 4 MG,3201668,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-PREVACID SOLUTAB DISINTEGRATING TAB 1,3201669,CDM,250,RC,,,outpatient,,,21.2,15.9,,16.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.53,16.96,
NF-DIOVAN ORAL TABLET 40MG,3201670,CDM,250,RC,,,outpatient,,,5.87,4.4,,4.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.36,4.7,
NF-ZEMPLAR LIQ CAP 2MCG,3201671,CDM,250,RC,,,outpatient,,,91.19,68.39,,72.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.69,72.95,
NF-PHOSLYRA ORAL SOLUTION 667MG/5ML,3201672,CDM,250,RC,,,outpatient,,,0.75,0.56,,0.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.3,0.6,
NF-HUMULIN 70/30 SUBQ SUSP 70U-30U/1ML,3201673,CDM,250,RC,,,outpatient,,,36.63,27.47,,29.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.74,29.3,
PR XR FLUORO FOR SPINE INJECTION,4010058,CDM,972,RC,7700326,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-XYZAL TAB 5MG,3201675,CDM,250,RC,,,outpatient,,,12.65,9.49,,10.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.09,10.12,
NORCO 10/325 TAB,3201676,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-FLUVOXAMINE MALEATE ORAL TABLET 25MG,3201677,CDM,250,RC,,,outpatient,,,8.52,6.39,,6.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.43,6.82,
NF-SYSTANE OPHTH SOLUTION,3201678,CDM,250,RC,,,outpatient,,,2.16,1.62,,1.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.87,1.73,
NF-CYCLOSPORINE CAP 25MG,3201679,CDM,250,RC,,,outpatient,,,8.6,6.45,,6.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.46,6.88,
NF-AMBIEN CR EXTENDED RELEASE TABLET 12.,3201680,CDM,250,RC,,,outpatient,,,37.37,28.03,,29.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.04,29.9,
NF-JALYN CAP 0.5MG-0.4MG,3201681,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-AZILECT TAB 0.5MG,3201682,CDM,250,RC,,,outpatient,,,64.38,48.29,,51.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.91,51.5,
NF-ACETYLCYSTEINE POWDER,3201683,CDM,250,RC,,,outpatient,,,2.27,1.7,,1.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.82,
NF-SKELAXIN ORAL TABLET 800MG,3201684,CDM,250,RC,,,outpatient,,,27.48,20.61,,21.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.06,21.98,
NF-CYCLOPHOSPHAMIDE IV PWD FOR SOLN 1GM,3201685,CDM,250,RC,,,outpatient,,,2510.6,1882.95,,2008.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1010.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1255.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1255.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1255.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1255.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1380.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1010.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1010.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2008.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1882.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2008.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1010.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2008.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1010.27,2008.48,
VANIQA CREAM 13.9%,3201686,CDM,637,RC,,,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
NF-ETODOLAC ORAL TABLET 400MG,3201687,CDM,250,RC,,,outpatient,,,7.55,5.66,,6.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.04,6.04,
NF-METHENAMINE HIPPURATE 1GM TABLET,3201688,CDM,250,RC,,,outpatient,,,7.74,5.81,,6.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.11,6.19,
NF-AZELASTINE HCL NASAL SPRAY 137MCG/1AC,3201689,CDM,250,RC,,,outpatient,,,12.97,9.73,,10.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.22,10.38,
NF-IRON TABLET 65MG,3201690,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-FOLIC ACID ORAL TABLET 0.8MG,3201691,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-VITAMIN D3 ORAL TABLET 5000IU,3201692,CDM,250,RC,,,outpatient,,,0.31,0.23,,0.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.25,
NF-SYSTANE ULTRA OPHTHALMIC SOLN 0.4%-0.,3201693,CDM,250,RC,,,outpatient,,,49.95,37.46,,39.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.1,39.96,
Cefdinir Capsules 300 mg,3201694,CDM,637,RC,,,outpatient,,,1.6,1.2,,1.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.64,1.28,
NF-TICLOPIDINE HCL TAB 250MG,3201695,CDM,250,RC,,,outpatient,,,10.08,7.56,,8.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.06,8.06,
NF-DORZOLAMIDE HCL-TIMOLOL 22.3MG-6.8MG/,3201697,CDM,250,RC,,,outpatient,,,84.72,63.54,,67.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.09,67.78,
NF-METAMUCIL MULTIHEALTH CAP 0.52GM,3201698,CDM,250,RC,,,outpatient,,,0.37,0.28,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
NF-OREGANO OIL,3201699,CDM,250,RC,,,outpatient,,,11.1,8.33,,8.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.47,8.88,
NF-LODOSYN TAB 25MG,3201700,CDM,250,RC,,,outpatient,,,19.77,14.83,,15.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.96,15.82,
PR XR IVP,4010072,CDM,972,RC,7440026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
DIOVAN 40 MG,3201703,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-SEROQUEL ORAL TABLET 400MG,3201704,CDM,250,RC,,,outpatient,,,86.05,64.54,,68.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.63,68.84,
NF-ARMOUR THYROID TAB 240MG,3201705,CDM,250,RC,,,outpatient,,,1.23,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
OFLOXACIN OTIC SOL 0.3%,3201706,CDM,637,RC,,,outpatient,,,2.03,1.52,,1.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.62,
NF-TENORETIC 100 ORAL TABLET 100MG-25MG,3201707,CDM,250,RC,,,outpatient,,,2.86,2.15,,2.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.15,2.29,
NF-CHLORTHALIDONE TAB 25MG,3201708,CDM,250,RC,,,outpatient,,,0.89,0.67,,0.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.36,0.71,
NF-CELEBREX CAP 50MG,3201709,CDM,250,RC,,,outpatient,,,7.24,5.43,,5.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.91,5.79,
NF-NUVIGIL ORAL TABLET 250MG,3201711,CDM,250,RC,,,outpatient,,,52.03,39.02,,41.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.94,41.62,
NF-CIMZIA SUBQ SOLN 200MG/1ML,3201712,CDM,250,RC,,,outpatient,,,9856.8,7392.6,,7885.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3966.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4928.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4928.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4928.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4928.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5421.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7885.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7392.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7392.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7392.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7392.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3966.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3966.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7885.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7392.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7885.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7885.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3966.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7885.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7885.44,
NF-VYVANSE CAP 60MG,3201713,CDM,250,RC,,,outpatient,,,27.02,20.27,,21.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.87,21.62,
NF-TIMOLOL MALEATE OPHTH GEL DROP 0.5%,3201714,CDM,250,RC,,,outpatient,,,43.29,32.47,,34.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.42,34.63,
NORCO 7.5/325,3201715,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-KOMBIGLYZE XR TAB ER 1000MG-2.5MG,3201716,CDM,250,RC,,,outpatient,,,18.2,13.65,,14.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.32,14.56,
NF-LIVALO TAB 2MG,3201717,CDM,250,RC,,,outpatient,,,20.25,15.19,,16.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,16.2,
NF-FIORINAL ORAL CAPSULE,3201718,CDM,250,RC,,,outpatient,,,4.21,3.16,,3.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.69,3.37,
ZOLEDRONIC ACID 4MG/100ML,3201719,CDM,636,RC,,,both,,,1250,937.5,,1000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,687.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,503,1000,
ZOLEDRONIC ACID 4MG/100ML,3201720,CDM,636,RC,,,both,,,1250,937.5,,1000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,687.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,503,1000,
PR XR METASTATIC SERIES/EXTR COMP,4010092,CDM,972,RC,7707526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-SAPHRIS SL TAB 10MG,3201722,CDM,250,RC,,,outpatient,,,51.04,38.28,,40.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.54,40.83,
NF-TRILEPTAL ORAL TABLET 600MG,3201723,CDM,250,RC,,,outpatient,,,37.28,27.96,,29.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15,29.82,
NF-FENOFIBRIC ACID ORAL CAPSULE DR 45MG,3201724,CDM,250,RC,,,outpatient,,,7.39,5.54,,5.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.97,5.91,
NF-MOTRIN CHILDREN'S SUSPENSION 100MG/5M,3201725,CDM,637,RC,,,outpatient,,,0.31,0.23,,0.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.25,
HUMALOG VIAL 3ML,3201726,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-ZONEGRAN CAP 100MG,3201727,CDM,250,RC,,,outpatient,,,11.29,8.47,,9.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.54,9.03,
NF-KOMBIGLYZE XR TAB ER 1000MG-5MG,3201729,CDM,250,RC,,,outpatient,,,36.4,27.3,,29.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.65,29.12,
SYNTHROID 0.137MG,3201730,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DALIRESP  500 mcg,3201731,CDM,637,RC,,,outpatient,,,8.54,6.41,,6.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.44,6.83,
NF-NORTRIPTYLINE HCL CAP 25MG,3201732,CDM,250,RC,,,outpatient,,,2.9,2.18,,2.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.17,2.32,
NF-METHOTREXATE INJECTION SOLUTION 25MG/,3201733,CDM,250,RC,,,outpatient,,,3.97,2.98,,3.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.6,3.18,
NF-SYSTANE BALANCE OPHTH SOLN 0.6%,3201734,CDM,250,RC,,,outpatient,,,3.86,2.9,,3.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.55,3.09,
NF-POTASSIUM CHLORIDE CAP ER 10MEQ,3201735,CDM,250,RC,,,outpatient,,,7.52,5.64,,6.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.03,6.02,
NF-REQUIP TAB 5MG,3201737,CDM,250,RC,,,outpatient,,,14.39,10.79,,11.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.79,11.51,
NF-SULFAZINE TABLET 500MG,3201739,CDM,250,RC,,,outpatient,,,0.87,0.65,,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.35,0.7,
NF-UNISOM TABLET 25MG,3201740,CDM,250,RC,,,outpatient,,,2.47,1.85,,1.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.99,1.98,
NF-VITAMIN B-6 ORAL TABLET 50MG,3201741,CDM,250,RC,,,outpatient,,,0.8,0.6,,0.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.32,0.64,
NF-TORSEMIDE INTRAVENOUS SOLUTION 10MG/1,3201742,CDM,637,RC,,,outpatient,,,9.53,7.15,,7.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,7.62,
NF-STARLIX TAB 120MG,3201744,CDM,250,RC,,,outpatient,,,5.56,4.17,,4.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.24,4.45,
NF-PACERONE TAB 200MG,3201745,CDM,637,RC,,,outpatient,,,12.21,9.16,,9.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.91,9.77,
NF-CYCLOSPORINE CAPSULE 25MG,3201746,CDM,250,RC,,,outpatient,,,5.09,3.82,,4.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.05,4.07,
NF-CYCLOSPORINE ORAL LIQUID CAPSULE 50MG,3201747,CDM,250,RC,,,outpatient,,,10.13,7.6,,8.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.08,8.1,
NF-ELIQUIS TAB 5MG,3201748,CDM,250,RC,,,outpatient,,,18.53,13.9,,14.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.46,14.82,
NF-FELDENE CAPSULE 20MG,3201749,CDM,250,RC,,,outpatient,,,26.19,19.64,,20.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.54,20.95,
NF-FLECAINIDE ACETATE TAB 50MG,3201750,CDM,250,RC,,,outpatient,,,9.77,7.33,,7.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.93,7.82,
NF-VALTREX ORAL TABLET 1GM,3201751,CDM,250,RC,,,outpatient,,,62.07,46.55,,49.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.98,49.66,
NF-SPRINTEC TAB 35MCG-0.25MG,3201752,CDM,250,RC,,,outpatient,,,4.26,3.2,,3.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.41,
NF-MICARDIS ORAL TABLET 20MG,3201753,CDM,250,RC,,,outpatient,,,19.83,14.87,,15.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.98,15.86,
NF-MICARDIS ORAL TABLET 40MG,3201754,CDM,250,RC,,,outpatient,,,7.92,5.94,,6.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.19,6.34,
NF-ESTRACE VAGINAL CREAM 0.1MG/1GM,3201755,CDM,250,RC,,,outpatient,,,14.8,11.1,,11.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.96,11.84,
NF-UTA CAPSULE,3201756,CDM,250,RC,,,outpatient,,,13.76,10.32,,11.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.54,11.01,
NF-CALCIUM 500 + D ORAL TABLET 400IU-500,3201760,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-INVOKANA ORAL TABLET 100MG,3201761,CDM,250,RC,,,outpatient,,,38.94,29.21,,31.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.67,31.15,
NF-UNIRETIC TAB 25MG-15MG,3201762,CDM,250,RC,,,outpatient,,,11.11,8.33,,8.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.47,8.89,
NF-PYRIDOSTIGMINE BROMIDE TAB 60MG,3201763,CDM,250,RC,,,outpatient,,,2.95,2.21,,2.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.19,2.36,
NF-MARINOL CAPSULE 2.5MG,3201764,CDM,250,RC,,,outpatient,,,33.64,25.23,,26.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.54,26.91,
NF-DIFLUCAN ORAL TABLET 150MG,3201767,CDM,250,RC,,,outpatient,,,130.76,98.07,,104.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.62,104.61,
NF-MOTRIN CHILDREN'S SUSP 100MG/5ML,3201769,CDM,250,RC,,,outpatient,,,0.31,0.23,,0.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.25,
NF-NORMOSOL-R INTRAVENOUS SOLUTION,3201770,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-NORMOSOL-R IV SOLN,3201771,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-NORMOSOL-R INTRAVENOUS SOLUTION,3201772,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
PR XR METASTATIC SERIES/W/O EXTREMITIES,4010093,CDM,972,RC,7707426,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-LOTEMAX OPHTHALMIC OINTMENT 0.5%,3201774,CDM,250,RC,,,outpatient,,,214.73,161.05,,171.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,118.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.41,171.78,
NF-QUALAQUIN CAP 324MG,3201775,CDM,250,RC,,,outpatient,,,29.07,21.8,,23.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.7,23.26,
NF-ZOFRAN ODT DISSOLVE TABLET 4MG,3201777,CDM,250,RC,,,outpatient,,,92.77,69.58,,74.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.33,74.22,
NF-REQUIP ORAL TABLET 2MG,3201778,CDM,250,RC,,,outpatient,,,9.32,6.99,,7.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.75,7.46,
NF-MEPRON SUSPENSION 750MG/5ML,3201779,CDM,250,RC,,,outpatient,,,14.41,10.81,,11.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.8,11.53,
NF-NORVIR CAPSULE 100MG,3201780,CDM,250,RC,,,outpatient,,,47.09,35.32,,37.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,37.67,
NF-REYATAZ CAP 300MG,3201781,CDM,250,RC,,,outpatient,,,161.1,120.83,,128.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.83,128.88,
NF-TRUVADA ORAL TABLET 200MG-300MG,3201782,CDM,250,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-PROMETRIUM LIQ CAP 100MG,3201783,CDM,250,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
"NF-VITAMIN A PALMITATE TABLET 15,000IU",3201784,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-FENOFIBRATE ORAL TABLET 48MG,3201785,CDM,250,RC,,,outpatient,,,6.94,5.21,,5.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.79,5.55,
NF-JENTADUETO ORAL TABLET 2.5MG-1000MG,3201786,CDM,250,RC,,,outpatient,,,18.78,14.09,,15.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.56,15.02,
NF-SPIRONOLACTONE 25MG ORAL TABLET,3201787,CDM,250,RC,,,outpatient,,,1.7,1.28,,1.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.36,
NF-ACCOLATE 10MG ORAL TABLET,3201788,CDM,250,RC,,,outpatient,,,7.61,5.71,,6.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.06,6.09,
NF-DEXAMETHASONE ORAL TABLET 2MG,3201789,CDM,250,RC,,,outpatient,,,7.05,5.29,,5.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.84,5.64,
NF-ZYVOX ORAL TABLET 600MG,3201790,CDM,250,RC,,,outpatient,,,675.21,506.41,,540.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,337.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,371.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,540.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,271.7,540.17,
NF-XIFAXAN ORAL TABLET 550MG,3201791,CDM,250,RC,,,outpatient,,,97.79,73.34,,78.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.35,78.23,
NF-APRI TAB 0.15MG-0.03MG-NA,3201792,CDM,250,RC,,,outpatient,,,4.03,3.02,,3.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.62,3.22,
NF-IRON 100 PLUS ORAL TABLET,3201793,CDM,250,RC,,,outpatient,,,1.14,0.86,,0.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.46,0.91,
ESTRADIOL 0.5MG,3201794,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-ALREX OPHTH SUSP 0.2%,3201795,CDM,250,RC,,,outpatient,,,123.42,92.57,,98.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.66,98.74,
NF-FLECAINIDE ACETATE TAB 50MG,3201796,CDM,250,RC,,,outpatient,,,9.02,6.77,,7.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.63,7.22,
NF-CYPROHEPTADINE HCL ORAL SYRUP 2MG/5ML,3201797,CDM,250,RC,,,outpatient,,,0.5,0.38,,0.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.4,
PR XR SMALL BOWEL,4010116,CDM,972,RC,7425026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-CITRACAL ULTRADENSE CAL CITR 200IU-31,3201801,CDM,250,RC,,,outpatient,,,0.26,0.2,,0.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.21,
NF-NATURES BLEND MULTI VITAMIN AND MINER,3201802,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-PRESERVISION ORAL LIQUID CAPSULE,3201803,CDM,250,RC,,,outpatient,,,0.94,0.71,,0.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.38,0.75,
NF-PREVACID CAP DR 15MG,3201804,CDM,250,RC,,,outpatient,,,22.2,16.65,,17.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.93,17.76,
NF-SODIUM CHLORIDE HYPERT OPHTH SOLUTION,3201805,CDM,250,RC,,,outpatient,,,3.64,2.73,,2.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.46,2.91,
NF-VISTARIL CAP 50MG,3201806,CDM,250,RC,,,outpatient,,,10.05,7.54,,8.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.04,8.04,
MINIVELLE 0.0375MG/DAY(BOX OF 8),3201807,CDM,637,RC,,,outpatient,,,100.95,75.71,,80.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.62,80.76,
NF-AFINITOR ORAL TABLET 10MG,3201808,CDM,250,RC,,,outpatient,,,1318.75,989.06,,1055,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,530.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,659.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,659.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,659.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,659.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,725.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1055,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,530.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,530.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1055,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,989.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1055,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1055,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,530.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1055,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,530.67,1055,
NF-AFINITOR ORAL TABLET 5MG,3201809,CDM,250,RC,,,outpatient,,,1250.51,937.88,,1000.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,687.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,937.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,503.21,1000.41,
NF-SANDOSTATIN INJ SOLN 100MCG/1ML,3201810,CDM,250,RC,,,outpatient,,,93.99,70.49,,75.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.82,75.19,
NF-XGEVA SUBQ SOLN 120MG/1.7ML,3201811,CDM,250,RC,,,outpatient,,,4391.42,3293.57,,3513.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1767.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2195.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2195.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2195.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2195.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2415.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3513.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3293.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3293.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3293.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3293.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1767.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1767.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3513.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3293.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3513.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3513.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1767.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3513.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1767.11,3513.14,
NF-CARMEX CLICK-STICK,3201812,CDM,250,RC,,,outpatient,,,0.63,0.47,,0.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.5,
NF-ALBUTEROL HFA INH AER PWD 0.09MG/1ACT,3201814,CDM,250,RC,,,outpatient,,,43.52,32.64,,34.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.51,34.82,
NF-NEUPRO TD PATCH ER 3MG/24HR,3201815,CDM,250,RC,,,outpatient,,,22.62,16.97,,18.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.1,18.1,
NF-BYDUREON SUBQ PWD FOR SUSP ER 2MG,3201816,CDM,250,RC,,,outpatient,,,418.77,314.08,,335.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,209.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,209.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,209.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,209.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,168.51,335.02,
NF-GLUCERNA 1.2 CAL ORAL LIQUID,3201819,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-INDOMETHACIN,3201820,CDM,250,RC,,,outpatient,,,4.1,3.08,,3.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.65,3.28,
NF-PARLODEL ORAL TABLET 2.5MG,3201821,CDM,250,RC,,,outpatient,,,24.67,18.5,,19.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.93,19.74,
NF-LINZESS CAP 145MCG,3201822,CDM,250,RC,,,outpatient,,,31.52,23.64,,25.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.68,25.22,
NF-MYRBETRIQ ORAL TABLET 25MG,3201823,CDM,250,RC,,,outpatient,,,30.86,23.15,,24.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.42,24.69,
NF-ZEGERID CAP 40MG-1100MG,3201824,CDM,250,RC,,,outpatient,,,51.59,38.69,,41.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.76,41.27,
NF-TROSPIUM CHLORIDE CAP ER 60MG,3201825,CDM,250,RC,,,outpatient,,,27.7,20.78,,22.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.15,22.16,
NF-NAC ORAL POWDER 1700MG,3201826,CDM,250,RC,,,outpatient,,,0.72,0.54,,0.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.29,0.58,
NF-INSULIN HUMAN ISOPHANE (NPH) SUBQ SUS,3201829,CDM,250,RC,,,outpatient,,,40.25,30.19,,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.2,32.2,
NF-VIT B-6 ORAL TABLET 100MG,3201830,CDM,250,RC,,,outpatient,,,1.03,0.77,,0.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.41,0.82,
NF-THIOTHIXENE CAP 2MG,3201831,CDM,250,RC,,,outpatient,,,1.12,0.84,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
B-6 50 mg,3201832,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-LITHOBID TAB ER 300MG,3201833,CDM,250,RC,,,outpatient,,,13.39,10.04,,10.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.39,10.71,
Leflunomide 20 mg,3201834,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MIDODRINE 2.5 MG,3201835,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-FLECAINIDE ACETATE TAB 100MG,3201836,CDM,250,RC,,,outpatient,,,11.46,8.6,,9.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.61,9.17,
NF-BRINTELLIX TAB 10MG,3201837,CDM,250,RC,,,outpatient,,,32.28,24.21,,25.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.99,25.82,
NF-FLUOCINONIDE CREAM 0.05%,3201838,CDM,250,RC,,,outpatient,,,7.88,5.91,,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.17,6.3,
NF-PENTASA CAP ER 250MG,3201839,CDM,250,RC,,,outpatient,,,7.57,5.68,,6.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.05,6.06,
NF-ATRIPLA ORAL TABLET 600MG-200MG-300MG,3201840,CDM,250,RC,,,outpatient,,,372.49,279.37,,297.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,186.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,149.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,149.89,297.99,
NF-HUMULIN 70-30 SUBQ SUSP 70U/1ML-30U/1,3201841,CDM,250,RC,,,outpatient,,,53.04,39.78,,42.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.34,42.43,
NF-COD LIVER OIL LIQUID FILLED CAPSULE,3201842,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-DEXAMETHASONE ORAL TABLET 0.75MG,3201843,CDM,250,RC,,,outpatient,,,2.74,2.06,,2.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.1,2.19,
NF-MEXILETINE HCL CAP 150MG,3201844,CDM,250,RC,,,outpatient,,,2.48,1.86,,1.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1,1.98,
NF-BROVANA INH SOLN 15MCG/2ML,3201845,CDM,250,RC,,,outpatient,,,19.14,14.36,,15.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.7,15.31,
PR XR UGI WITH SBFT,4010128,CDM,972,RC,7424526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-DISULFIRAM TAB 500MG,3201848,CDM,250,RC,,,outpatient,,,9.14,6.86,,7.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.68,7.31,
Fenofibric Acid 45 mg,3201850,CDM,637,RC,,,outpatient,,,1.8,1.35,,1.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.72,1.44,
NF-EXELON TD PATCH ER 13.3MG/24HR,3201851,CDM,250,RC,,,outpatient,,,46.05,34.54,,36.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.53,36.84,
NF-NEUPRO TD PATCH ER 1MG/24HR,3201852,CDM,250,RC,,,outpatient,,,73.13,54.85,,58.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.43,58.5,
NF-SUTENT CAP 50MG,3201853,CDM,250,RC,,,outpatient,,,1881.39,1411.04,,1505.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,757.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,940.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,940.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,940.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,940.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1034.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,757.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,757.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1505.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1411.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1505.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,757.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1505.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,757.07,1505.11,
NF-ELIQUIS ORAL TABLET 2.5MG,3201854,CDM,250,RC,,,outpatient,,,21.58,16.19,,17.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.68,17.26,
NF-MYLANTA SUSPENSION,3201855,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-PREMPRO LOW DOSE TAB 0.45MG-1.5MG,3201856,CDM,250,RC,,,outpatient,,,12.11,9.08,,9.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.87,9.69,
NF-NEO/POLYMYX/DEX OPHTHALMIC OINTMENT,3201857,CDM,250,RC,,,outpatient,,,19.12,14.34,,15.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.69,15.3,
NF-ERYTHROMYCIN CAP DR 250MG,3201858,CDM,250,RC,,,outpatient,,,1.98,1.49,,1.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.58,
NF-HYDROXYZINE HCL ORAL SYRUP 10MG/5ML,3201859,CDM,250,RC,,,outpatient,,,0.26,0.2,,0.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.21,
LISINOPRIL/HCTZ 10/12.5,3201861,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NF-COSOPT OCUMETER PLUS OPHTH SOLN 2%-0.,3201862,CDM,250,RC,,,outpatient,,,62.49,46.87,,49.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.15,49.99,
NF-SODIUM CHLORIDE HYPERT OPHTH OINTMENT,3201863,CDM,250,RC,,,outpatient,,,15.59,11.69,,12.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.27,12.47,
NF-SYSTANE OPHTHALMIC GEL/JELLY 0.3%,3201864,CDM,250,RC,,,outpatient,,,3.77,2.83,,3.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.52,3.02,
NF-FLUNISOLIDE NASAL SPRAY 0.025MG/1ACT,3201865,CDM,250,RC,,,outpatient,,,6.88,5.16,,5.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,5.5,
NF-VORICONAZOLE ORAL TABLET 200MG,3201867,CDM,250,RC,,,outpatient,,,171.81,128.86,,137.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.14,137.45,
NF-MEROPENEM IV PWD FOR SOLN 1GM,3201868,CDM,250,RC,,,outpatient,,,260.37,195.28,,208.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.77,208.3,
NF-TRIBENZOR ORAL TABLET 10-12.5-40MG,3201870,CDM,250,RC,,,outpatient,,,26.73,20.05,,21.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.76,21.38,
NF-ZENPEP CAP DR,3201871,CDM,250,RC,,,outpatient,,,17.42,13.07,,13.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.01,13.94,
Oxcarbazepine 600 mg,3201872,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
"NF-BETA CAROTENE CAPSULE 10,000IU",3201875,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-HALOPERIDOL DECANOATE IM OIL 100MG/1M,3201876,CDM,250,RC,,,outpatient,,,219.11,164.33,,175.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.17,175.29,
LEVOTHYROXINE SODIUM 200 MCG,3201877,CDM,637,RC,,,outpatient,,,1.2,0.9,,0.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.48,0.96,
NF-ROBAFEN COUGH ORAL LIQUID CAPSULE 15M,3201878,CDM,250,RC,,,outpatient,,,1.05,0.79,,0.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.42,0.84,
NF-DORZOLAMIDE HCL OPHTH SOLN 2%,3201879,CDM,250,RC,,,outpatient,,,24.94,18.71,,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.04,19.95,
NF-PREDNISOLONE ACETATE OPHTH SUSP 1%,3201880,CDM,250,RC,,,outpatient,,,40.9,30.68,,32.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.46,32.72,
NF-TRAVATAN OPHTH SOLN 0.004%,3201881,CDM,250,RC,,,outpatient,,,120.98,90.74,,96.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.68,96.78,
NF-NAMENDA XR CAP ER 28MG,3201882,CDM,250,RC,,,outpatient,,,40.5,30.38,,32.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.3,32.4,
NF-THERATEARS OPHTHALMIC SOLUTION,3201883,CDM,250,RC,,,outpatient,,,1.7,1.28,,1.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.36,
NF-ZORVOLEX CAP 18MG,3201884,CDM,250,RC,,,outpatient,,,11.1,8.33,,8.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.47,8.88,
NF-METHYLPREDNISOLONE ACETATE TAB 4MG,3201885,CDM,250,RC,,,outpatient,,,5.87,4.4,,4.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.36,4.7,
NF-BROMOCRIPTINE MESYLATE ORAL TABLET 2.,3201886,CDM,250,RC,,,outpatient,,,8.1,6.08,,6.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.26,6.48,
NF-EZETIMIBE ORAL TABLET 10MG,3201888,CDM,250,RC,,,outpatient,,,11.37,8.53,,9.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.58,9.1,
NF-PLENDIL TAB ER 2.5MG,3201890,CDM,250,RC,,,outpatient,,,10.88,8.16,,8.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.38,8.7,
Plendil 2.5 mg,3201892,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Fusion Plus Capsule,3201893,CDM,637,RC,,,outpatient,,,1.02,0.77,,0.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.41,0.82,
NF-ENEMA RECTAL LIQUID,3201894,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-THYROID ORAL TABLET 90MG,3201895,CDM,250,RC,,,outpatient,,,0.89,0.67,,0.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.36,0.71,
NF-VISION FORMULA TABLET,3201896,CDM,250,RC,,,outpatient,,,0.32,0.24,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-TAMIFLU CAP 30MG,3201897,CDM,250,RC,,,outpatient,,,45.07,33.8,,36.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.14,36.06,
NF-CHOLECALCIFEROL CRYSTAL,3201898,CDM,250,RC,,,outpatient,,,888,666,,710.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,444,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,444,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,444,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,444,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,488.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,357.33,710.4,
NF-FARXIGA ORAL TABLET 10MG,3201899,CDM,250,RC,,,outpatient,,,42.8,32.1,,34.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.22,34.24,
NF-ONGLYZA ORAL TABLET 5MG,3201900,CDM,250,RC,,,outpatient,,,41.28,30.96,,33.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.61,33.02,
NF-ESTROGEN/PROGESTIN/FOLATE COMBINATION,3201901,CDM,250,RC,,,outpatient,,,49.1,36.83,,39.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.76,39.28,
NF-LUNESTA ORAL TABLET 3MG,3201902,CDM,250,RC,,,outpatient,,,19.91,14.93,,15.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.01,15.93,
NF-COLON HERBAL CLEANSER CAPSULE,3201903,CDM,250,RC,,,outpatient,,,0.28,0.21,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-DIGESTIVE AID #34 ORAL TABLET 34MG-34,3201904,CDM,250,RC,,,outpatient,,,0.24,0.18,,0.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.19,
NF-LEFLUNOMIDE ORAL TABLET 20MG,3201905,CDM,250,RC,,,outpatient,,,60.7,45.53,,48.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.43,48.56,
TAMIFLU 30  MG,3201907,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
TAMIFLU SUSP. 6MG/ML,3201908,CDM,637,RC,,,outpatient,,,144.95,108.71,,115.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.33,115.96,
NF-ENBREL SUBCUTANEOUS SOLUTION 50MG/1ML,3201909,CDM,250,RC,,,outpatient,,,3059.07,2294.3,,2447.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1682.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1230.97,2447.26,
NF-ENBREL SUBCUTANEOUS SOLUTION 50MG/1ML,3201910,CDM,250,RC,,,outpatient,,,3059.07,2294.3,,2447.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1682.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2294.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1230.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2447.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1230.97,2447.26,
NF-DIETHYLPROPION HCL TAB ER 75MG,3201911,CDM,250,RC,,,outpatient,,,4.87,3.65,,3.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,3.9,
TriNessa 28 day,3201912,CDM,637,RC,,,outpatient,,,12.91,9.68,,10.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.19,10.33,
NF-ISOSOURCE HN LIQUID,3201913,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-MYZILRA ORAL TAB,3201914,CDM,250,RC,,,outpatient,,,3.63,2.72,,2.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.46,2.9,
NF-POTASSIUM GLUCONATE ORAL TABLET 595MG,3201915,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-MYCOPHENOLATE MOFETIL CAP 250MG,3201916,CDM,250,RC,,,outpatient,,,29.1,21.83,,23.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.71,23.28,
NF-TACROLIMUS CAP 1MG,3201917,CDM,250,RC,,,outpatient,,,19.34,14.51,,15.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.78,15.47,
NF-MYCOPHENOLATE MOFETIL CAP 250MG,3201918,CDM,250,RC,,,outpatient,,,29.91,22.43,,23.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.04,23.93,
NF-MINOXIDIL ORAL TABLET 10MG,3201919,CDM,250,RC,,,outpatient,,,7.83,5.87,,6.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.15,6.26,
NF-DDAVP TAB 0.1MG,3201920,CDM,250,RC,,,outpatient,,,27.64,20.73,,22.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.12,22.11,
NF-CALCIUM 600 CAPSULE 600MG,3201921,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
Bumetanide 0.5 mg tab,3201922,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-FLUNISOLIDE NASAL SPRAY 0.025MG/1ACT,3201923,CDM,250,RC,,,outpatient,,,7.35,5.51,,5.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.96,5.88,
NF-TEGRETOL-XR TABLET 400MG,3201924,CDM,250,RC,,,outpatient,,,3.74,2.81,,2.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.5,2.99,
PR XR TRANSCATH RAD,4010139,CDM,972,RC,7589826,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
BYSTOLIC 10 MG,3201926,CDM,637,RC,,,outpatient,,,3.6,2.7,,2.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.45,2.88,
NF-VANCOMYCIN HCL CAP 125MG,3201927,CDM,250,RC,,,outpatient,,,128.85,96.64,,103.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.85,103.08,
NF-JANUMET XR ORAL TAB ER 1000MG-100MG,3201928,CDM,250,RC,,,outpatient,,,44.52,33.39,,35.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.91,35.62,
NF-NEXIUM CAP DR 20MG,3201929,CDM,250,RC,,,outpatient,,,35.04,26.28,,28.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.1,28.03,
NF-ACIPHEX ENTERIC COATED TABLET 20MG,3201930,CDM,250,RC,,,outpatient,,,34.01,25.51,,27.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.69,27.21,
NF-MAGNESIUM OXIDE TABLET 250MG,3201931,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-PROBIOTIC DIGESTIVE CARE ORAL TAB 10M,3201932,CDM,637,RC,,,outpatient,,,2.24,1.68,,1.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.9,1.79,
NF-ISOSOURCE 1.5 CAL LIQUID,3201933,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-INVEGA EXTENDED RELEASE TABLET 9MG,3201936,CDM,250,RC,,,outpatient,,,161.96,121.47,,129.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.17,129.57,
KANGAROO FEED/FLUSH BAG,3201937,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-TOBRAMYCIN 300MG/5ML INHALATION SOLUT,3201938,CDM,250,RC,,,outpatient,,,95.29,71.47,,76.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.34,76.23,
NF-ROWASA KIT,3201939,CDM,250,RC,,,outpatient,,,5070.52,3802.89,,4056.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2040.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2535.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2535.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2535.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2535.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2788.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4056.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3802.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3802.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3802.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3802.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2040.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2040.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4056.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3802.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4056.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4056.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2040.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4056.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2040.38,4056.42,
NF-BRINTELLIX 5MG ORAL TABLET,3201940,CDM,250,RC,,,outpatient,,,35.47,26.6,,28.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.27,28.38,
Mesalamine 4g/60ml Enema,3201941,CDM,637,RC,,,outpatient,,,14.91,11.18,,11.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,11.93,
NF-HALCION 0.25MG ORAL TABLET,3201942,CDM,250,RC,,,outpatient,,,13.55,10.16,,10.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.45,10.84,
NF-OFLOXACIN 0.3% OPHTHALMIC SOLUTION,3201943,CDM,250,RC,,,outpatient,,,16.48,12.36,,13.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.63,13.18,
NF-METHYLERGONOVINE MALEATE 0.2MG ORAL T,3201944,CDM,250,RC,,,outpatient,,,35.96,26.97,,28.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.47,28.77,
"NF-CARDIZEM LA 180MG ORAL TABLET, EXTEND",3201945,CDM,250,RC,,,outpatient,,,18.59,13.94,,14.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.48,14.87,
NF-LOESTRIN 21 1.5/30 30MCG-1.5MG ORAL T,3201946,CDM,250,RC,,,outpatient,,,8.07,6.05,,6.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.25,6.46,
NF-PRAZOSIN HCL 1MG ORAL CAPSULE,3201947,CDM,250,RC,,,outpatient,,,2.76,2.07,,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.11,2.21,
NF-OLANZAPINE 20MG ORAL TABLET,3201948,CDM,250,RC,,,outpatient,,,88.76,66.57,,71.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.72,71.01,
NF-PEPTO BISMOL 262MG/15ML ORAL SUSPENSI,3201949,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-ZIOPTAN 0.0015% OPHTHALMIC SOLUTION,3201951,CDM,250,RC,,,outpatient,,,15.36,11.52,,12.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.18,12.29,
ELIQUIS 5 MG,3201952,CDM,637,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
NF-SUBOXONE SL FILM 8MG-2MG,3201953,CDM,250,RC,,,outpatient,,,31.25,23.44,,25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.58,25,
NF-RAPAMUNE TAB 1MG,3201954,CDM,250,RC,,,outpatient,,,74.76,56.07,,59.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.08,59.81,
TOVIAZ 4 MG,3201955,CDM,637,RC,,,outpatient,,,7.4,5.55,,5.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.98,5.92,
NF-NAMENDA XR CAP ER 28MG,3201956,CDM,250,RC,,,outpatient,,,43.94,32.96,,35.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.68,35.15,
NF-PROTONIX INJECTION 40MG,3201957,CDM,637,RC,,,outpatient,,,106.56,79.92,,85.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.88,85.25,
"NF-LOVAZA 1GM ORAL CAPSULE, LIQUID FILLE",3201958,CDM,250,RC,,,outpatient,,,4.62,3.47,,3.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.86,3.7,
"NF-FENOFIBRIC ACID 135MG ORAL CAPSULE, D",3201959,CDM,250,RC,,,outpatient,,,22.21,16.66,,17.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,17.77,
NF-GABAPENTIN 300MG ORAL CAPSULE,3201960,CDM,250,RC,,,outpatient,,,4.92,3.69,,3.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.98,3.94,
NF-LOSARTAN POTASSIUM-HYDROCHLOROTHIAZID,3201961,CDM,250,RC,,,outpatient,,,12.61,9.46,,10.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.07,10.09,
NF-DOMPERIDONE POWDER,3201962,CDM,250,RC,,,outpatient,,,305.47,229.1,,244.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,122.92,244.38,
NF-LEENA 35MCG-0.5MG ORAL TABLET,3201963,CDM,250,RC,,,outpatient,,,5.2,3.9,,4.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.09,4.16,
NF-BUFFERED SALT 287MG-15MG-180MG ORAL T,3201964,CDM,250,RC,,,outpatient,,,0.17,0.13,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-GLIPIZIDE AND METFORMIN HYDROCHLORIDE,3201965,CDM,250,RC,,,outpatient,,,3.66,2.75,,2.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.47,2.93,
NF-INDAPAMIDE TAB 1.25MG,3201966,CDM,250,RC,,,outpatient,,,0.85,0.64,,0.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.34,0.68,
BRILINTA 90 MG,3201967,CDM,637,RC,,,outpatient,,,5.05,3.79,,4.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.03,4.04,
NF-DESOGEN TAB 0.15MG-0.03MG-NA,3201968,CDM,250,RC,,,outpatient,,,7.56,5.67,,6.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.04,6.05,
NF-VITAMIN B12 1000MCG ORAL TABLET,3201969,CDM,250,RC,,,outpatient,,,1.31,0.98,,1.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.53,1.05,
NF-CALCIUM 600/VITAMIN D 600MG-125IU ORA,3201970,CDM,250,RC,,,outpatient,,,0.32,0.24,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-SENNALAX-S 50MG-8.6MG ORAL TABLET,3201971,CDM,250,RC,,,outpatient,,,1.05,0.79,,0.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.42,0.84,
NF-RESTASIS 0.05% OPHTHALMIC EMULSION,3201972,CDM,250,RC,,,outpatient,,,18.25,13.69,,14.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.34,14.6,
NF-ALEVE 220MG ORAL TABLET,3201973,CDM,250,RC,,,outpatient,,,0.4,0.3,,0.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.32,
NF-LOTREL 10MG-20MG ORAL CAPSULE,3201974,CDM,250,RC,,,outpatient,,,23.53,17.65,,18.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.47,18.82,
NF-INTELENCE 200MG ORAL TABLET,3201975,CDM,250,RC,,,outpatient,,,80.65,60.49,,64.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.45,64.52,
NF-EPIVIR 10MG/ML ORAL SOLUTION,3201976,CDM,250,RC,,,outpatient,,,2.05,1.54,,1.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.64,
NF-ZIAGEN 20MG/ML ORAL SOLUTION,3201977,CDM,250,RC,,,outpatient,,,2.72,2.04,,2.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.18,
NF-METHYLPREDNISOLONE ACETATE TAB 4MG,3201978,CDM,250,RC,,,outpatient,,,5.29,3.97,,4.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,4.23,
NF-RAPAMUNE TAB 2MG,3201979,CDM,250,RC,,,outpatient,,,149.51,112.13,,119.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.16,119.61,
Fenobibric Acid DR 135 mg,3201980,CDM,637,RC,,,outpatient,,,2.25,1.69,,1.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.8,
NF-OSMOLITE ROSS READY-TO-HANG LIQUID,3201981,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-TWOCAL HN LIQUID,3201982,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
COLY-MYCIN S OTIC,3201983,CDM,637,RC,,,outpatient,,,35.25,26.44,,28.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.18,28.2,
PR US GUIDED NEEDLE PLACEMENT FOR BIOPSY,4010185,CDM,972,RC,1908326,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-GRISEOFULVIN ORAL TABLET 500MG,3201985,CDM,250,RC,,,outpatient,,,12.29,9.22,,9.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.95,9.83,
NF-NUVIGIL 150MG ORAL TABLET,3201986,CDM,250,RC,,,outpatient,,,43.79,32.84,,35.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.62,35.03,
"NF-ROPINIROLE 4MG ORAL TABLET, EXTENDED",3201988,CDM,250,RC,,,outpatient,,,20.24,15.18,,16.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.14,16.19,
NF-VYVANSE 20MG ORAL CAPSULE,3201989,CDM,250,RC,,,outpatient,,,27.81,20.86,,22.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.19,22.25,
NF-QVAR 0.04MG/ACTUATION INHALATION AERO,3201990,CDM,250,RC,,,outpatient,,,15.97,11.98,,12.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,12.78,
"NF-LOVAZA 1GM ORAL CAPSULE, LIQUID FILLE",3201991,CDM,250,RC,,,outpatient,,,7.18,5.39,,5.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,5.74,
NF-VYTORIN 10MG-40MG ORAL TABLET,3201992,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-HYDRALAZINE HCL 50MG ORAL TABLET,3201993,CDM,250,RC,,,outpatient,,,1.96,1.47,,1.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.79,1.57,
EXFORGE 5/160/12.5,3201994,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-CREON 15000U-3000U-9500U ORAL CAPSULE,3201995,CDM,250,RC,,,outpatient,,,4.37,3.28,,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.76,3.5,
NF-CALCIUM CARBONATE 1250MG ORAL TABLET,3201996,CDM,250,RC,,,outpatient,,,0.61,0.46,,0.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.49,
NF-DOXAZOSIN MESYLATE 8MG ORAL TABLET,3201997,CDM,250,RC,,,outpatient,,,5.51,4.13,,4.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.22,4.41,
NF-PREDNISONE 10MG ORAL TABLET,3201998,CDM,250,RC,,,outpatient,,,1.86,1.4,,1.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.75,1.49,
NF-DEXILANT DELAYED-RELEASE CAPSULE 60MG,3201999,CDM,250,RC,,,outpatient,,,27.21,20.41,,21.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.95,21.77,
ABILIFY 10MG TAB,3202000,CDM,637,RC,,,outpatient,,,21.95,16.46,,17.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.83,17.56,
ABILIFY 5MG TAB,3202001,CDM,637,RC,,,outpatient,,,21.95,16.46,,17.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.83,17.56,
ACCOLATE 10MG TAB,3202002,CDM,637,RC,,,outpatient,,,2.3,1.73,,1.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.84,
ACCOLATE 20MG TAB,3202003,CDM,637,RC,,,outpatient,,,2.3,1.73,,1.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.84,
ACCUPRIL 10MG TAB,3202004,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ACCUPRIL 20MG TAB,3202005,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PR XR ESOPHOGRAM,4010188,CDM,972,RC,7422026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
ACTIGALL 300MG (URSODIOL),3202007,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ACETIC ACID 0.25% 1000ML,3202008,CDM,637,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
ACTIVATED CHARCOAL (AQUEOUS),3202009,CDM,637,RC,,,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,11.6,
ACTOS 30MG TAB,3202010,CDM,637,RC,,,outpatient,,,10.75,8.06,,8.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.33,8.6,
ACTOS 45MG TAB,3202011,CDM,637,RC,,,outpatient,,,11.65,8.74,,9.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.69,9.32,
ACULAR 0.5% 5ML,3202012,CDM,637,RC,,,outpatient,,,3.65,2.74,,2.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.47,2.92,
PR XR FISTULAGRAM,4010189,CDM,972,RC,7608026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
PR XR FLUORO-NEEDLE PLACEMENT,4010192,CDM,972,RC,7700226,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
ADVAIR DISKUS 100/50,3202015,CDM,637,RC,,,outpatient,,,223.65,167.74,,178.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90,178.92,
ADVAIR DISKUS 250/50,3202016,CDM,637,RC,,,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,85.6,
ADVAIR DISKUS 500/50,3202017,CDM,637,RC,,,outpatient,,,206.51,154.88,,165.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,103.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,83.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,83.1,165.21,
ADVIL 200MG TAB,3202018,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
AFRIN NASAL SPRAY,3202019,CDM,637,RC,,,outpatient,,,2.25,1.69,,1.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.8,
AGGRENOX 200/25MG CAP,3202020,CDM,637,RC,,,outpatient,,,4.4,3.3,,3.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.77,3.52,
PR XR SWALLOWING FUNCTION FLUORO,4010193,CDM,972,RC,7423026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
PR  XR UGI WITH SBFT,4010195,CDM,972,RC,7424526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-MUCINEX EXTENDED-RELEASE TABLET 1200M,3202023,CDM,250,RC,,,outpatient,,,2.91,2.18,,2.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.17,2.33,
NF-POTASSIUM GLUCONATE 550MG ORAL TABLET,3202024,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-QUESTRAN 4GM/9GM ORAL POWDER FOR SUSP,3202025,CDM,250,RC,,,outpatient,,,15.19,11.39,,12.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.11,12.15,
NF-MULTI VITAMINS ORAL TABLET,3202026,CDM,250,RC,,,outpatient,,,0.5,0.38,,0.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.4,
NF-DESONIDE CREAM 0.05%,3202027,CDM,250,RC,,,outpatient,,,19.8,14.85,,15.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.97,15.84,
NF-FLUVOXAMINE MALEATE 50MG ORAL TABLET,3202028,CDM,250,RC,,,outpatient,,,15.43,11.57,,12.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.21,12.34,
NF-FLUVOXAMINE MALEATE ORAL TABLET 50MG,3202029,CDM,250,RC,,,outpatient,,,9.48,7.11,,7.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.81,7.58,
NF-NIACIN 500MG ORAL TABLET,3202030,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-LISINOPRIL 2.5MG ORAL TABLET,3202031,CDM,250,RC,,,outpatient,,,4.75,3.56,,3.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.91,3.8,
NF-DESONIDE OINT 0.05%,3202033,CDM,250,RC,,,outpatient,,,14.82,11.12,,11.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.96,11.86,
NF-SM CALCIUM CITRATE + D 315MG-200IU OR,3202034,CDM,250,RC,,,outpatient,,,0.34,0.26,,0.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.27,
NF-PEPCID 40MG ORAL TABLET,3202035,CDM,250,RC,,,outpatient,,,28.89,21.67,,23.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.63,23.11,
NF-TYLENOL SUSP 160MG-1MG-5MG-2.5MG/5ML,3202038,CDM,637,RC,,,outpatient,,,0.17,0.13,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-ESTROGEL TRANSDERMAL GEL 0.06%,3202039,CDM,250,RC,,,outpatient,,,4.07,3.05,,3.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.64,3.26,
NF-ATROPINE SULFATE 1% OPHTHALMIC SOLUTI,3202041,CDM,250,RC,,,outpatient,,,5.71,4.28,,4.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.3,4.57,
NF-SUBOXONE 8MG-2MG SUBLINGUAL FILM,3202042,CDM,250,RC,,,outpatient,,,31.25,23.44,,25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.58,25,
NF-OXYCODONE HCL ORAL TABLET 30MG,3202043,CDM,250,RC,,,outpatient,,,7.15,5.36,,5.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.88,5.72,
NF-NOVOLIN 70/30 SUBQ SUSP 70U-30U/1ML,3202044,CDM,250,RC,,,outpatient,,,28.15,21.11,,22.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.33,22.52,
NF-PHOSPHA 250 NEUTRAL TAB 155MG-852MG-1,3202045,CDM,250,RC,,,outpatient,,,1.88,1.41,,1.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.76,1.5,
NF-VITAMIN B-100 NATURAL TABLET,3202046,CDM,250,RC,,,outpatient,,,0.61,0.46,,0.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.49,
EDARBYCLOR 40MG/12.5MG,3202047,CDM,637,RC,,,outpatient,,,5.92,4.44,,4.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.38,4.74,
NF-QVAR INH/NEB AER LIQ 0.04MG/1 ACTUATI,3202048,CDM,250,RC,,,outpatient,,,4.18,3.14,,3.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.68,3.34,
NF-ACTIVE FE TAB,3202049,CDM,250,RC,,,outpatient,,,11.84,8.88,,9.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.76,9.47,
NF-CHLORPROMAZINE HCL ORAL TABLET 10MG,3202051,CDM,250,RC,,,outpatient,,,2.56,1.92,,2.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.03,2.05,
NF-XELJANZ ORAL TABLET 5MG,3202052,CDM,250,RC,,,outpatient,,,173.79,130.34,,139.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.93,139.03,
NF-GLYBURIDE MICRO/METFORMIN 2.5MG-500MG,3202053,CDM,250,RC,,,outpatient,,,2.46,1.85,,1.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.99,1.97,
NF-BICLORA-D ORAL TABLET 25MG-25MG-60MG,3202054,CDM,250,RC,,,outpatient,,,1.77,1.33,,1.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.71,1.42,
NF-CARBA-XP LIQ 20MG-100MG/5ML,3202055,CDM,250,RC,,,outpatient,,,0.83,0.62,,0.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.33,0.66,
NF-METHYLERGONOVINE MALEATE TAB 0.2MG,3202056,CDM,250,RC,,,outpatient,,,27.1,20.33,,21.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.91,21.68,
CLINDAMYCIN 300 MG CAP,3202057,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-HYOSCYAMINE ORAL LIQUID 0.125MG/1ML,3202059,CDM,250,RC,,,outpatient,,,4.31,3.23,,3.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.73,3.45,
NF-POTASSIUM GLUCONATE TABLET 595MG,3202060,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-ROCEPHIN POWDER FOR INJ 1GM,3202063,CDM,250,RC,,,outpatient,,,231.29,173.47,,185.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,93.07,185.03,
NF-NYSTATIN 100000U/ML ORAL SUSPENSION,3202064,CDM,250,RC,,,outpatient,,,0.71,0.53,,0.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.29,0.57,
NF-JEVITY 1.5 CAL LIQUID,3202065,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-PRILOSEC ORAL CAPSULE DR 20MG,3202066,CDM,250,RC,,,outpatient,,,23.51,17.63,,18.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,18.81,
NF-ZESTORETIC ORAL TABLET 10MG-12.5MG,3202067,CDM,250,RC,,,outpatient,,,4.74,3.56,,3.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.91,3.79,
NF-AMARYL TAB 1MG,3202068,CDM,250,RC,,,outpatient,,,4.03,3.02,,3.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.62,3.22,
NF-FENOFIBRATE ORAL TABLET 48MG,3202069,CDM,250,RC,,,outpatient,,,7.07,5.3,,5.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.84,5.66,
NF-GABITRIL ORAL TABLET 4MG,3202070,CDM,250,RC,,,outpatient,,,7.76,5.82,,6.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.12,6.21,
NF-CALCIUM + D 500MG-125IU ORAL TABLET,3202071,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-PROBENECID-COLCHICINE 0.5MG-500MG ORA,3202072,CDM,250,RC,,,outpatient,,,10.68,8.01,,8.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.3,8.54,
NF-TRIBENZOR 5MG-12.5MG-20MG ORAL TABLET,3202074,CDM,250,RC,,,outpatient,,,22.82,17.12,,18.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.18,18.26,
NF-REVLIMID CAP 15MG,3202075,CDM,250,RC,,,outpatient,,,2022.91,1517.18,,1618.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,814.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1011.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1011.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1011.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1011.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1112.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1618.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,814.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,814.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1618.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1517.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1618.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1618.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,814.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1618.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,814.02,1618.33,
NF-DELTA D3 TABLET 400IU,3202076,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-BIDIL ORAL TABLET 37.5MG-20MG,3202077,CDM,250,RC,,,outpatient,,,9.03,6.77,,7.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.63,7.22,
NF-FLECAINIDE ACETATE ORAL TABLET 50MG,3202079,CDM,250,RC,,,outpatient,,,6.44,4.83,,5.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,5.15,
NF-ARAVA ORAL TABLET 20MG,3202080,CDM,250,RC,,,outpatient,,,80.53,60.4,,64.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.41,64.42,
NF-GABITRIL TAB 4MG,3202081,CDM,250,RC,,,outpatient,,,7.64,5.73,,6.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.07,6.11,
NF-VENLAFAXINE HCL CAP ER 37.5MG,3202082,CDM,250,RC,,,outpatient,,,29.78,22.34,,23.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.98,23.82,
NF-CLOBETASOL PROPIONATE CREAM 0.05%,3202083,CDM,250,RC,,,outpatient,,,31.63,23.72,,25.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.73,25.3,
NF-HUMIRA SUBQ KIT 40MG/0.8ML,3202084,CDM,250,RC,,,outpatient,,,5994.7,4496.03,,4795.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2412.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2997.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2997.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2997.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2997.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3297.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4795.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2412.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2412.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4795.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4795.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4795.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2412.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4795.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2412.27,4795.76,
NF-DEXAMETHASONE TAB  0.75MG,3202088,CDM,250,RC,,,outpatient,,,2.52,1.89,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2.02,
NF-HYOSCYAMINE SULFATE CAP ER 0.375MG,3202089,CDM,250,RC,,,outpatient,,,1.88,1.41,,1.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.76,1.5,
OXYCODONE HCL 5 MG,3202090,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ERYTHROMYCIN 250 MG DR CAP.,3202091,CDM,637,RC,,,outpatient,,,3.8,2.85,,3.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.53,3.04,
NF-OMEPRAZOLE CAP DR 40MG,3202092,CDM,250,RC,,,outpatient,,,21.98,16.49,,17.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.84,17.58,
"NF-CO Q-10 10MG ORAL CAPSULE, LIQUID FIL",3202093,CDM,250,RC,,,outpatient,,,1.53,1.15,,1.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.62,1.22,
NF-AVIANE 0.02MG-0.1MG ORAL TABLET,3202094,CDM,250,RC,,,outpatient,,,4.65,3.49,,3.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.87,3.72,
NF-BARIUM SULFATE SUSP 0.1%,3202095,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-BACLOFEN ORAL TAB 20MG,3202096,CDM,250,RC,,,outpatient,,,4.39,3.29,,3.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.77,3.51,
NF-SOMA ORAL TABLET 250MG,3202098,CDM,250,RC,,,outpatient,,,21.44,16.08,,17.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,17.15,
NF-ZORVOLEX CAP 35MG,3202099,CDM,250,RC,,,outpatient,,,11.99,8.99,,9.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.82,9.59,
NF-ZYRTEC-D 12HR ORAL TABLET ER 5MG-120M,3202100,CDM,250,RC,,,outpatient,,,5.68,4.26,,4.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.29,4.54,
NF-NORCO 7.5MG-325MG ORAL TABLET,3202101,CDM,250,RC,,,outpatient,,,9.54,7.16,,7.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.84,7.63,
NF-OPTIVAR OPHTH SOLN 0.05%,3202102,CDM,250,RC,,,outpatient,,,42.24,31.68,,33.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17,33.79,
NF-BRIMONIDINE TARTRATE OPHTH SOLN 0.15%,3202103,CDM,250,RC,,,outpatient,,,88.73,66.55,,70.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.7,70.98,
VENLAFAXINE  37.5 MG,3202104,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-QVAR INH/NEB AER LIQ 0.08MG/1 ACTUATI,3202105,CDM,250,RC,,,outpatient,,,71.3,53.48,,57.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.69,57.04,
NF-FOCALIN TAB 5MG,3202106,CDM,250,RC,,,outpatient,,,2.7,2.03,,2.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.16,
NF-FOCALIN XR EXTENDED-RELEASE CAPSULE 2,3202107,CDM,250,RC,,,outpatient,,,35.15,26.36,,28.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.14,28.12,
NF-TENEX ORAL TABLET 2MG,3202108,CDM,250,RC,,,outpatient,,,15.36,11.52,,12.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.18,12.29,
NF-LIMBITROL DS 25MG-10MG ORAL TABLET,3202109,CDM,250,RC,,,outpatient,,,6.98,5.24,,5.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.81,5.58,
NF-PROTEIN ORAL POWDER FOR SUSPENSION,3202110,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-PRENATAL VITAMINS PLUS 1MG-27MG ORAL,3202111,CDM,250,RC,,,outpatient,,,1.11,0.83,,0.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.89,
"NF-BETA CAROTENE CAPSULE 25,000IU",3202112,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-ANDROGEL GEL 1%,3202113,CDM,250,RC,,,outpatient,,,17.15,12.86,,13.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.9,13.72,
NF-CREON ORAL DELAYED RELEASE CAPSULE,3202115,CDM,250,RC,,,outpatient,,,20.4,15.3,,16.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.21,16.32,
NF-FLUDROCORTISONE ACETATE ORAL TAB 0.1M,3202116,CDM,250,RC,,,outpatient,,,6.42,4.82,,5.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.58,5.14,
NF-MEVACOR TAB 40MG,3202117,CDM,250,RC,,,outpatient,,,26.78,20.09,,21.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.78,21.42,
Z PAK   500 MG TRI PAK,3202118,CDM,637,RC,,,outpatient,,,4.81,3.61,,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.94,3.85,
NF-SULFASALAZINE ORAL TABLET 500MG,3202119,CDM,250,RC,,,outpatient,,,1.15,0.86,,0.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.46,0.92,
NF-SYMBYAX CAP 6MG-50MG,3202120,CDM,250,RC,,,outpatient,,,59.54,44.66,,47.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.96,47.63,
NF-VITAMIN E CAPSULE 1000IU,3202121,CDM,250,RC,,,outpatient,,,0.49,0.37,,0.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.39,
NF-CETAPHIL MOISTURIZER CREAM,3202122,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
NF-DOVONEX CRM 0.005%,3202123,CDM,250,RC,,,outpatient,,,29.87,22.4,,23.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.02,23.9,
NF-SULAR TAB ER 34MG,3202125,CDM,250,RC,,,outpatient,,,58.74,44.06,,46.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.64,46.99,
NF-CORTEF TAB 10MG,3202126,CDM,250,RC,,,outpatient,,,3.73,2.8,,2.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.5,2.98,
TAMBOCAR 50 mg,3202127,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-FENOFIBRATE ORAL TABLET 160MG,3202128,CDM,250,RC,,,outpatient,,,21.16,15.87,,16.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.51,16.93,
NF-TOLTERODINE TARTRATE CAP ER 2MG,3202129,CDM,250,RC,,,outpatient,,,36.01,27.01,,28.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.81,
Triam/Hctz 75/50,3202130,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Lisinopril 40 mg,3202131,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-REFRESH PM OPHTH OINTMENT,3202132,CDM,250,RC,,,outpatient,,,6.3,4.73,,5.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.54,5.04,
NF-STRATTERA CAP 25MG,3202133,CDM,250,RC,,,outpatient,,,41.25,30.94,,33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.6,33,
NF-ACEON ORAL TABLET 2MG,3202134,CDM,250,RC,,,outpatient,,,9.33,7,,7.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.75,7.46,
NF-BIOFREEZE GEL 0.2%-3.5%,3202135,CDM,250,RC,,,outpatient,,,0.74,0.56,,0.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.3,0.59,
NF-CO Q-10 CAPSULE 50MG,3202136,CDM,250,RC,,,outpatient,,,1.38,1.04,,1.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.1,
NF-SAVELLA ORAL TABLET 25MG,3202137,CDM,250,RC,,,outpatient,,,16.9,12.68,,13.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.8,13.52,
NF-CULTURELLE ORAL CAPSULE 10 BILLION OR,3202139,CDM,250,RC,,,outpatient,,,1.66,1.25,,1.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.67,1.33,
NF-FENOFIBRIC ACID ORAL TABLET 35MG,3202140,CDM,250,RC,,,outpatient,,,3.7,2.78,,2.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.49,2.96,
PR FINE NEEDLE ASPIRATION IN RAD.,4010200,CDM,972,RC,10022,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
RABIES VACCINE (RabAvert),3202142,CDM,250,RC,,,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,600,
NF-DIPYRIDAMOLE 75MG ORAL TABLET,3202143,CDM,250,RC,,,outpatient,,,4.66,3.5,,3.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.88,3.73,
NF-OMEGA 3 CAPSULE 1000MG,3202144,CDM,250,RC,,,outpatient,,,0.26,0.2,,0.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.21,
NF-FLAVOXATE HCL ORAL TABLET 100MG,3202145,CDM,250,RC,,,outpatient,,,5.41,4.06,,4.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.18,4.33,
NF-THYROID TAB 15MG,3202146,CDM,250,RC,,,outpatient,,,1.4,1.05,,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.12,
NF-SILENOR ORAL TABLET 3MG,3202147,CDM,250,RC,,,outpatient,,,44.37,33.28,,35.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.85,35.5,
NF-THERATEARS OPHTH SOLUTION 0.25%,3202148,CDM,250,RC,,,outpatient,,,1.81,1.36,,1.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.45,
NF-BYSTOLIC 10MG ORAL TABLET,3202149,CDM,250,RC,,,outpatient,,,13.71,10.28,,10.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.52,10.97,
NF-INDAPAMIDE 1.25MG ORAL TABLET,3202150,CDM,250,RC,,,outpatient,,,0.53,0.4,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-XYZAL ORAL TABLET 5MG,3202151,CDM,250,RC,,,outpatient,,,20.02,15.02,,16.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.06,16.02,
NF-POTASSIUM GLUCONATE NATURAL TABLET 55,3202152,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-TRI-SPRINTEC TAB 35MCG-0.18MG;35MCG-0,3202153,CDM,250,RC,,,outpatient,,,5.2,3.9,,4.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.09,4.16,
Paroxetine 40 mg,3202154,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-PERCOCET 10MG-325MG ORAL TABLET,3202155,CDM,250,RC,,,outpatient,,,39.71,29.78,,31.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.98,31.77,
Premarin 0.45 mg,3202156,CDM,637,RC,,,outpatient,,,4.2,3.15,,3.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.69,3.36,
NF-VERAPAMIL HCL ORAL TAB ER 180MG,3202157,CDM,250,RC,,,outpatient,,,5.02,3.77,,4.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.02,4.02,
SEROQUEL XR 150 MG,3202158,CDM,637,RC,,,outpatient,,,14.88,11.16,,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,11.9,
LANTUS 10 ML VIAL,3202159,CDM,250,RC,,,outpatient,,,233.43,175.07,,186.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,93.93,186.74,
NF-LANSOPRAZOLE CAP DR 15MG,3202160,CDM,250,RC,,,outpatient,,,23.13,17.35,,18.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.31,18.5,
NF-SEROQUEL XR TAB ER 50MG,3202161,CDM,250,RC,,,outpatient,,,33.76,25.32,,27.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.59,27.01,
NF-INTELENCE ORAL TABLET 200MG,3202162,CDM,250,RC,,,outpatient,,,74.76,56.07,,59.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.08,59.81,
NF-ISENTRESS TAB 400MG,3202163,CDM,250,RC,,,outpatient,,,89.13,66.85,,71.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.87,71.3,
NF-LAMIVUDINE HBV ORAL TABLET 100MG,3202164,CDM,250,RC,,,outpatient,,,59.61,44.71,,47.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.99,47.69,
NF-PRIMAQUINE PHOSPHATE ORAL TABLET 26.3,3202165,CDM,250,RC,,,outpatient,,,7.48,5.61,,5.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.01,5.98,
NF-QVAR INH/NEB AER LIQ 0.08MG/1 ACTUATI,3202166,CDM,250,RC,,,outpatient,,,79.64,59.73,,63.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.05,63.71,
VIT K 5mg TAB  (Phytonadione),3202168,CDM,637,RC,,,outpatient,,,4.6,3.45,,3.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.85,3.68,
NF-DEMEROL HCL INJ SOLN 100MG/1ML,3202169,CDM,250,RC,,,outpatient,,,5.08,3.81,,4.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.04,4.06,
NF-QVAR INH/NEB AER LIQ 0.08MG/1 ACTUATI,3202170,CDM,250,RC,,,outpatient,,,21.08,15.81,,16.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.48,16.86,
NF-VIT. B COMPLEX AND MINERAL-VIT. B COM,3202171,CDM,250,RC,,,outpatient,,,10.59,7.94,,8.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.26,8.47,
NF-OXYCODONE HCL ORAL TABLET 15MG,3202172,CDM,250,RC,,,outpatient,,,15.36,11.52,,12.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.18,12.29,
NF-EX-L TABLET,3202173,CDM,250,RC,,,outpatient,,,0.37,0.28,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
NF-CLIMARA TD PATCH ER 0.1MG/24HR,3202174,CDM,250,RC,,,outpatient,,,115.37,86.53,,92.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.42,92.3,
NF-PREPARATION H OINTMENT,3202176,CDM,250,RC,,,outpatient,,,0.47,0.35,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
COZAAR 25 mg,3202178,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-DEXILANT CAP DR 60MG,3202179,CDM,250,RC,,,outpatient,,,29.91,22.43,,23.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.04,23.93,
NF-KOMBIGLYZE XR TAB ER 1000MG-2.5MG,3202180,CDM,250,RC,,,outpatient,,,21.88,16.41,,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.8,17.5,
NF-LEVEMIR FLEXPEN SUBQ SOLN 100U/1ML,3202181,CDM,250,RC,,,outpatient,,,128.18,96.14,,102.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.58,102.54,
NF-PRAVASTATIN SODIUM ORAL TABLET 10MG,3202182,CDM,250,RC,,,outpatient,,,11.9,8.93,,9.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.79,9.52,
NF-VICTOZA SUBQ SOLN 6MG/1ML,3202183,CDM,250,RC,,,outpatient,,,290.38,217.79,,232.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.85,232.3,
NF-FLEBOGAMMA 5% DIF IV SOLN 5GM/100ML,3202184,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
PR US PELVIC WALL BUTTOCK PERINEUM ST,4011150,CDM,972,RC,7685726,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-ZESTRIL ORAL TABLET 2.5MG,3202186,CDM,250,RC,,,outpatient,,,3.79,2.84,,3.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.53,3.03,
NF-LODINE TABLET 400MG,3202187,CDM,250,RC,,,outpatient,,,8.63,6.47,,6.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.47,6.9,
NF-NAMENDA XR CAP ER 14MG,3202188,CDM,250,RC,,,outpatient,,,43.94,32.96,,35.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.68,35.15,
NF-YAZ 28 3MG-0.02MG ORAL TABLET,3202189,CDM,250,RC,,,outpatient,,,14.37,10.78,,11.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.78,11.5,
NF-ADDERALL ORAL TABLET 20MG,3202190,CDM,250,RC,,,outpatient,,,12.91,9.68,,10.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.19,10.33,
NF-TUDORZA PRESSAIR INH AER PWD 400MCG/1,3202191,CDM,250,RC,,,outpatient,,,1249.42,937.07,,999.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,687.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,502.77,999.54,
NF-POTASSIUM CHLORIDE GRANULE,3202192,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
Methylphenidate 5mg,3202193,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
Oxybutynin Chloride ER 10 mg,3202194,CDM,637,RC,,,outpatient,,,2.71,2.03,,2.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.17,
NF-SUPER B100 ORAL TABLET,3202195,CDM,250,RC,,,outpatient,,,0.58,0.44,,0.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.46,
NF-ALENDRONATE SOD ORAL TABLET 70MG,3202196,CDM,250,RC,,,outpatient,,,71.51,53.63,,57.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.78,57.21,
NF-POTASSIUM CITRATE ORAL TAB ER 10MEQ,3202197,CDM,637,RC,,,outpatient,,,2.03,1.52,,1.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.62,
NF-JANUMET ORAL TABLET 50MG-1000MG,3202198,CDM,250,RC,,,outpatient,,,24.47,18.35,,19.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.85,19.58,
NF-LYSINE TABLET 1000MG,3202199,CDM,250,RC,,,outpatient,,,0.29,0.22,,0.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.23,
NF-OMEPRAZOLE CAP DR 20MG,3202200,CDM,250,RC,,,outpatient,,,21.09,15.82,,16.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.49,16.87,
NF-NEPRO LIQUID,3202201,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-COENZYME Q-10 CHEWABLE TAB 100MG,3202203,CDM,250,RC,,,outpatient,,,3.37,2.53,,2.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.36,2.7,
NF-GINKO BILOBA CAPSULE 120MG,3202204,CDM,250,RC,,,outpatient,,,0.49,0.37,,0.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.39,
NF-NEPRO WITH CARB STEADY ORAL LIQUID,3202205,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-ADVAIR HFA 115/21 INH AER 115MCG-21MC,3202206,CDM,250,RC,,,outpatient,,,110.23,82.67,,88.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.36,88.18,
NF-DESONIDE LOT 0.05%,3202208,CDM,250,RC,,,outpatient,,,13.75,10.31,,11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.53,11,
NF-ARMOUR THYROID ORAL TABLET 90MG,3202209,CDM,250,RC,,,outpatient,,,1.42,1.07,,1.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.57,1.14,
NF-B COMPLEX 50 TABLET,3202210,CDM,250,RC,,,outpatient,,,0.23,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-DEPAKOTE DELAYED-RELEASE TABLET 250MG,3202211,CDM,250,RC,,,outpatient,,,9.93,7.45,,7.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4,7.94,
NF-DEPAKOTE DELAYED-RELEASE TABLET 250MG,3202212,CDM,250,RC,,,outpatient,,,7.09,5.32,,5.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.85,5.67,
NF-FOLIVANE-PLUS CAP,3202213,CDM,250,RC,,,outpatient,,,2.4,1.8,,1.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.92,
Boudreaux's Butt Paste,3202214,CDM,637,RC,,,outpatient,,,13.2,9.9,,10.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.31,10.56,
NF-DEPAKOTE DELAYED-RELEASE TABLET 250MG,3202215,CDM,250,RC,,,outpatient,,,11.4,8.55,,9.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.59,9.12,
Divalproex Sod. DR  250 mg,3202216,CDM,637,RC,,,outpatient,,,4.61,3.46,,3.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.86,3.69,
NF-KETOTIFEN FUMARATE OPHTH SOLN 0.025%,3202217,CDM,250,RC,,,outpatient,,,35.41,26.56,,28.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.25,28.33,
NF-RESTORIL CAP 7.5MG,3202218,CDM,250,RC,,,outpatient,,,30.36,22.77,,24.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.22,24.29,
NF-NORTRIPTYLINE HCL CAP 25MG,3202220,CDM,250,RC,,,outpatient,,,0.99,0.74,,0.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.79,
ZOVIRAX ORAL SUSP. 200MG/5ML,3202221,CDM,637,RC,,,outpatient,,,2.85,2.14,,2.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.15,2.28,
NF-TOBRAMYCIN INH SOLN 300MG/5ML,3202222,CDM,250,RC,,,outpatient,,,116.36,87.27,,93.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.82,93.09,
NF-ORENCIA PWD FOR SOLN 250MG,3202223,CDM,250,RC,,,outpatient,,,3236.35,2427.26,,2589.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1302.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1618.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1618.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1618.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1618.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1779.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2589.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1302.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1302.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2589.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2427.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2589.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2589.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1302.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2589.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1302.31,2589.08,
NF-TRILIPIX CAP DR 135MG,3202224,CDM,250,RC,,,outpatient,,,21.07,15.8,,16.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.48,16.86,
NF-ADIPEX-P CAP 37.5MG,3202225,CDM,250,RC,,,outpatient,,,2.28,1.71,,1.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.92,1.82,
NF-HCTZ/TRIAMTERENE TABLET 50MG-75MG,3202226,CDM,637,RC,,,outpatient,,,3.66,2.75,,2.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.47,2.93,
NF-PROPRANOLOL ER ORAL CAP ER 80MG,3202227,CDM,250,RC,,,outpatient,,,13.58,10.19,,10.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.46,10.86,
NF-PROAIR HFA AER PWD 0.09MG/1ACT,3202229,CDM,637,RC,,,outpatient,,,15.98,11.99,,12.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,12.78,
NF-NICARDIPINE HCL IV SOLN 2.5MG/1ML,3202230,CDM,250,RC,,,outpatient,,,37.03,27.77,,29.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.9,29.62,
PR SML BOWEL FOL THRU DOUB CONT AFT UGI,4011155,CDM,972,RC,7424826,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-DESMOPRESSIN ACETATE ORAL TABLET 0.2M,3202232,CDM,250,RC,,,outpatient,,,17.45,13.09,,13.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.02,13.96,
NF-STRATTERA CAP 40MG,3202233,CDM,250,RC,,,outpatient,,,44.8,33.6,,35.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.03,35.84,
CARDENE 25MG/10 INJ,3202234,CDM,250,RC,,,outpatient,,,81.4,61.05,,65.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.76,65.12,
NF-ALIGN ORAL CAPSULE 4MG,3202235,CDM,637,RC,,,outpatient,,,3.29,2.47,,2.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.32,2.63,
NF-CHANTIX ORAL TABLET 1MG,3202236,CDM,250,RC,,,outpatient,,,12.54,9.41,,10.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.05,10.03,
NF-CYCLOPENTOLATE HCL OPHTH SOLN 0.5%,3202237,CDM,250,RC,,,outpatient,,,19.09,14.32,,15.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.68,15.27,
NF-FENOFIBRATE CAP 200MG,3202238,CDM,250,RC,,,outpatient,,,11.66,8.75,,9.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.69,9.33,
NF-SAVELLA ORAL TABLET 100MG,3202239,CDM,250,RC,,,outpatient,,,9.45,7.09,,7.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.8,7.56,
NF-MSM CAPSULE 1000MG,3202240,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-RISAQUAD ORAL CAPSULE,3202241,CDM,250,RC,,,outpatient,,,4.53,3.4,,3.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.82,3.62,
Lotrimin Ultra Cream 1 % 30 gm,3202242,CDM,637,RC,,,outpatient,,,12.4,9.3,,9.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.99,9.92,
NF-SOLU-MEDROL INJ PWD FOR SOLN 125MG,3202243,CDM,637,RC,,,outpatient,,,24.94,18.71,,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.04,19.95,
NF-SINGULAIR PKT 4MG/PACKET,3202244,CDM,250,RC,,,outpatient,,,27.62,20.72,,22.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.11,22.1,
NF-K-DUR TAB ER 20MEQ,3202245,CDM,637,RC,,,outpatient,,,3.98,2.99,,3.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.6,3.18,
NF-ALBUMIN HUMAN INTRAVENOUS SOLN 25%,3202246,CDM,250,RC,,,outpatient,,,4.77,3.58,,3.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.92,3.82,
NF-ITRACONAZOLE CAP 100MG,3202247,CDM,250,RC,,,outpatient,,,42.32,31.74,,33.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.03,33.86,
Itraconazole 100 mg Capsule,3202250,CDM,637,RC,,,outpatient,,,2.95,2.21,,2.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.19,2.36,
TRI PREVIFEM,3202251,CDM,637,RC,,,outpatient,,,145.48,109.11,,116.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.54,116.38,
NF-GUAIFENESIN ORAL TABLET 400MG,3202252,CDM,250,RC,,,outpatient,,,11.03,8.27,,8.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.44,8.82,
NF-CYCLOPENTOLATE HCL OPHTH SOLN 1%,3202254,CDM,250,RC,,,outpatient,,,12.36,9.27,,9.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.97,9.89,
METFORMIN ER 750 MG,3202255,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-ACIDOPHILUS CAPSULE,3202256,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
NF-ISOSORBIDE DINITRATE ORAL TABLET 2.5M,3202257,CDM,250,RC,,,outpatient,,,0.76,0.57,,0.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.31,0.61,
NF-BACITRACIN ZN/POLYMYXIN B SULF OINTME,3202258,CDM,250,RC,,,outpatient,,,1.78,1.34,,1.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.72,1.42,
NF-POLY-TUSSIN SOLN 6MG-5MG-12MG/5ML,3202260,CDM,250,RC,,,outpatient,,,0.5,0.38,,0.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.4,
NF-LECITHIN CAPSULE 1200MG,3202262,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-PAREGORIC LIQ 2MG/5ML,3202263,CDM,250,RC,,,outpatient,,,1.73,1.3,,1.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.38,
NF-BENICAR HCT ORAL TABLET 40MG-12.5MG,3202264,CDM,250,RC,,,outpatient,,,27.26,20.45,,21.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.97,21.81,
NF-PROGESTERONE LIQ CAP 200MG,3202266,CDM,250,RC,,,outpatient,,,15.57,11.68,,12.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.27,12.46,
PR US ART DOP-UNILA UPPER EXT,4110006,CDM,972,RC,9393126,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-ORENCIA INTRAVENOUS PWD FOR SOLN 250M,3202269,CDM,250,RC,,,outpatient,,,3362.6,2521.95,,2690.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1353.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1681.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1681.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1681.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1681.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1849.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2690.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2521.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2521.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2521.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2521.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1353.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1353.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2690.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2521.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2690.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2690.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1353.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2690.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1353.11,2690.08,
NF-IMMUNE GLOBULIN IV SOLN 5GM/100ML,3202270,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
NF-IMMUNE GLOBULIN IV SOLN 5GM/100ML,3202271,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
PR US SOFT TISSUES OF NECK,4110008,CDM,972,RC,7653626,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-FENOFIBRATE ORAL TABLET 48MG,3202273,CDM,250,RC,,,outpatient,,,6.66,5,,5.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.68,5.33,
NF-SAMSCA ORAL TABLET 15MG,3202274,CDM,250,RC,,,outpatient,,,1387.5,1040.63,,1110,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,558.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,693.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,693.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,693.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,693.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,763.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1040.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,558.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,558.33,1110,
NF-PROGESTERONE LIQ CAP 200MG,3202275,CDM,250,RC,,,outpatient,,,14.98,11.24,,11.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.03,11.98,
NF-VIVELLE TRANSDERM PATCH 0.1MG/24HRS,3202276,CDM,250,RC,,,outpatient,,,17.96,13.47,,14.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.23,14.37,
NF-VITAMIN D3 ORAL TABLET 1000IU,3202278,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
NF-METHYLPREDNISOLONE ACETATE TAB 4MG,3202279,CDM,250,RC,,,outpatient,,,9.22,6.92,,7.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.71,7.38,
DECADRON 100MG/10ML,3202280,CDM,250,RC,,,outpatient,,,29.7,22.28,,23.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.95,23.76,
PR US CAROTID DOPPLER UNI/LIMITED RT,4110011,CDM,972,RC,9388226RT,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-ROPINIROLE HCL TAB 4MG,3202284,CDM,250,RC,,,outpatient,,,9.61,7.21,,7.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.87,7.69,
NF-LEADER CO Q10 ORAL CAPSULE 100MG,3202285,CDM,250,RC,,,outpatient,,,0.39,0.29,,0.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.31,
NF-NOVOLIN 70/30 SUBQ SUSP 70U-30U/1ML,3202286,CDM,250,RC,,,outpatient,,,15.26,11.45,,12.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.14,12.21,
NF-VIVELLE-DOT TD PATCH ER 0.1MG/24HR,3202287,CDM,250,RC,,,outpatient,,,34.18,25.64,,27.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.75,27.34,
NF-DEXILANT CAP DR 60MG,3202288,CDM,250,RC,,,outpatient,,,20.39,15.29,,16.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.2,16.31,
NF-INSPRA ORAL TABLET 25MG,3202289,CDM,250,RC,,,outpatient,,,29.86,22.4,,23.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.02,23.89,
NF-AZOR ORAL TABLET 10MG-20MG,3202290,CDM,250,RC,,,outpatient,,,24.42,18.32,,19.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.83,19.54,
NF-METOLAZONE ORAL TABLET 2.5MG,3202291,CDM,250,RC,,,outpatient,,,4.91,3.68,,3.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.98,3.93,
NF-NEPRO WITH CARB STEADY ORAL SOLUTION,3202292,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-MORPHINE SULFATE CAP ER 50MG,3202293,CDM,637,RC,,,outpatient,,,107.85,80.89,,86.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.4,86.28,
NF-CASODEX TAB 50MG,3202294,CDM,250,RC,,,outpatient,,,77.71,58.28,,62.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.27,62.17,
NF-RISPERDAL CONSTA IM PWD FOR SUSP ER 2,3202295,CDM,250,RC,,,outpatient,,,1515.74,1136.81,,1212.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,757.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,833.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,609.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,609.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1212.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1136.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1212.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1212.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,609.93,1212.59,
NF-VIIBRYD ORAL TABLET 40MG,3202296,CDM,250,RC,,,outpatient,,,28.05,21.04,,22.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.29,22.44,
NF-ZIOPTAN OPHTH SOLN 0.0015%,3202297,CDM,250,RC,,,outpatient,,,51.2,38.4,,40.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.6,40.96,
NF-LAMICTAL XR EXTENDED RELEASE TABLET 5,3202298,CDM,250,RC,,,outpatient,,,66.86,50.15,,53.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.9,53.49,
NF-CREON CAP DR,3202299,CDM,250,RC,,,outpatient,,,10.99,8.24,,8.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.42,8.79,
NF-OMEPRAZOLE CAP DR 40MG,3202300,CDM,250,RC,,,outpatient,,,27.37,20.53,,21.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.01,21.9,
NF-IMMUNE GLOBULIN IV PWD FOR SOLN 10GM,3202303,CDM,250,RC,,,outpatient,,,5025.64,3769.23,,4020.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2022.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2512.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2512.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2512.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2512.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2764.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4020.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3769.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3769.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3769.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3769.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2022.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2022.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4020.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3769.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4020.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4020.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2022.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4020.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2022.32,4020.51,
NF-FRAGMIN SUBCUTANEOUS SOLN 15000IU/0.6,3202304,CDM,250,RC,,,outpatient,,,786.99,590.24,,629.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,316.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,393.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,393.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,393.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,393.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,432.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,316.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,590.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,629.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,316.68,629.59,
FLUOXETINE HCL ORAL CAPSULE 40MG,3202305,CDM,637,RC,,,outpatient,,,6.45,4.84,,5.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.6,5.16,
NF-CO Q-10 ORAL LIQ CAP 200MG,3202306,CDM,250,RC,,,outpatient,,,2.71,2.03,,2.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.17,
NF-GLUCOSAMINE & CHONDROITIN 500MG-400MG,3202308,CDM,250,RC,,,outpatient,,,5.55,4.16,,4.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.23,4.44,
NF-MAGNESIUM CHELATED TABLET 100MG,3202309,CDM,250,RC,,,outpatient,,,0.15,0.11,,0.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.12,
NF-BYSTOLIC ORAL TABLET 20MG,3202310,CDM,250,RC,,,outpatient,,,13.93,10.45,,11.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.61,11.14,
NF-REQUIP XL ORAL TAB ER 8MG,3202311,CDM,250,RC,,,outpatient,,,45.29,33.97,,36.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.22,36.23,
NF-MOVANTIK ORAL TABLET 25MG,3202312,CDM,250,RC,,,outpatient,,,36.94,27.71,,29.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.86,29.55,
NF-CHLORHEXIDINE GLUCONATE LIQ 0.12%,3202313,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-FOLIC ACID ORAL TABLET 0.4MG,3202314,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-KETOCONAZOLE ORAL TABLET 200MG,3202315,CDM,250,RC,,,outpatient,,,3.28,2.46,,2.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.32,2.62,
NF-MARINOL CAPSULE 2.5MG,3202316,CDM,250,RC,,,outpatient,,,33.53,25.15,,26.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.49,26.82,
NF-BYETTA SUBCUTANEOUS SOLUTION 250MCG/1,3202317,CDM,250,RC,,,outpatient,,,636.44,477.33,,509.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,318.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,318.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,318.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,318.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,256.1,509.15,
PR US CHEST,4110012,CDM,972,RC,7660426,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-BACITRACIN OPHTH OINTMENT 500U/GM,3202319,CDM,250,RC,,,outpatient,,,12.64,9.48,,10.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.09,10.11,
NF-LEVITRA ORAL TABLET 20MG,3202320,CDM,250,RC,,,outpatient,,,47.27,35.45,,37.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.02,37.82,
NF-ORTHO TRI-CYCLEN KIT,3202321,CDM,250,RC,,,outpatient,,,0.84,0.63,,0.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.34,0.67,
NF-DESIPRAMINE HCL ORAL TABLET 25MG,3202322,CDM,250,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
NF-ASPERCREME TOPICAL CREAM 10%,3202324,CDM,250,RC,,,outpatient,,,0.55,0.41,,0.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.22,0.44,
NF-LUNESTA ORAL TABLET 3MG,3202325,CDM,250,RC,,,outpatient,,,18.02,13.52,,14.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.25,14.42,
NF-LAMISIL AT ATHLETE'S FOOT CREAM 1%,3202326,CDM,250,RC,,,outpatient,,,3.31,2.48,,2.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.33,2.65,
PREVIFEM ORAL KIT,3202331,CDM,637,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-NEXIUM CAP DR 40MG,3202332,CDM,250,RC,,,outpatient,,,37.14,27.86,,29.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.95,29.71,
NF-NEXIUM CAP DR 40MG,3202333,CDM,250,RC,,,outpatient,,,44.02,33.02,,35.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.22,
NF-PHILITH ORAL TABLET,3202334,CDM,250,RC,,,outpatient,,,5.92,4.44,,4.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.38,4.74,
NF-PAMINE FORTE ORAL TABLET 5MG,3202335,CDM,250,RC,,,outpatient,,,20.43,15.32,,16.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.22,16.34,
NF-VITAMIN C/ROSE HIPS TABLET 1000MG,3202336,CDM,250,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
NF-CIPRODEX OTIC SUSP 0.3%-0.1%,3202338,CDM,250,RC,,,outpatient,,,103.9,77.93,,83.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.81,83.12,
NF-METHYLPREDNISOLONE ACETATE TAB 4MG,3202339,CDM,250,RC,,,outpatient,,,2.57,1.93,,2.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.03,2.06,
NF-SEROQUEL ORAL TABLET 300MG,3202340,CDM,250,RC,,,outpatient,,,29.86,22.4,,23.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.02,23.89,
NF-LAMOTRIGINE CHEW TAB 25MG,3202341,CDM,250,RC,,,outpatient,,,39.32,29.49,,31.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.82,31.46,
NF-PENTAZOCIN/NALOXONE ORAL TAB 50MG-0.5,3202342,CDM,250,RC,,,outpatient,,,6.16,4.62,,4.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.48,4.93,
NF-JARDIANCE ORAL TABLET 25MG,3202343,CDM,250,RC,,,outpatient,,,50.74,38.06,,40.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.42,40.59,
NF-LANTUS SOLOSTAR SUBQ SOLN 100U/1ML,3202344,CDM,250,RC,,,outpatient,,,110.34,82.76,,88.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.4,88.27,
NF-MECLIZINE HCL ORAL TABLET 12.5MG,3202345,CDM,250,RC,,,outpatient,,,1.2,0.9,,0.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.48,0.96,
NF-COENZYME Q10 CAPSULE 100MG,3202346,CDM,250,RC,,,outpatient,,,2.73,2.05,,2.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.1,2.18,
NF-NOVAPLUS VENTOLIN HFA 0.09MG/1ACT,3202347,CDM,250,RC,,,outpatient,,,10.01,7.51,,8.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.03,8.01,
"NF-LITHOBID TABLET, EXTENDED RELEASE 300",3202348,CDM,250,RC,,,outpatient,,,21.98,16.49,,17.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.84,17.58,
NF-ZYPREXA ORAL TABLET 20MG,3202349,CDM,250,RC,,,outpatient,,,120.25,90.19,,96.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.39,96.2,
NF-PHENOBARBITAL TAB 100MG,3202350,CDM,250,RC,,,outpatient,,,0.27,0.2,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-OMEPRAZOLE CAP DR 40MG,3202351,CDM,250,RC,,,outpatient,,,27.08,20.31,,21.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.9,21.66,
NF-LORAZEPAM ORAL SOLUTION 2MG/1ML,3202352,CDM,250,RC,,,outpatient,,,4.88,3.66,,3.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.96,3.9,
NF-EXEMESTANE ORAL TABLET 25MG,3202353,CDM,250,RC,,,outpatient,,,74.86,56.15,,59.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.12,59.89,
"NF-FLORANEX TABLET, CHEWABLE 0.2MG-0.2MG",3202354,CDM,250,RC,,,outpatient,,,0.63,0.47,,0.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.5,
NF-SALSALATE ORAL TABLET 500MG,3202356,CDM,250,RC,,,outpatient,,,0.93,0.7,,0.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.37,0.74,
NF-RESTORIL CAPSULE 7.5MG,3202357,CDM,250,RC,,,outpatient,,,58.22,43.67,,46.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.43,46.58,
NF-CAPOZIDE 50/25 ORAL TABLET 50MG-25MG,3202358,CDM,250,RC,,,outpatient,,,8.01,6.01,,6.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.41,
ARMOUR THYROID TABLET 90MG,3202359,CDM,637,RC,,,outpatient,,,1.1,0.83,,0.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.44,0.88,
NF-LYRICA CAP 150MG,3202360,CDM,250,RC,,,outpatient,,,25.66,19.25,,20.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.33,20.53,
NF-SUCRALFATE ORAL TABLET 1GM,3202361,CDM,250,RC,,,outpatient,,,2.78,2.09,,2.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,2.22,
NF-OMEPRAZOLE CAP DR 20MG,3202362,CDM,250,RC,,,outpatient,,,19.58,14.69,,15.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.88,15.66,
NF-JUBLIA SOLN 10%,3202363,CDM,250,RC,,,outpatient,,,547.73,410.8,,438.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,220.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,273.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,273.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,273.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,273.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,438.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,220.41,438.18,
NF-QNASL NASAL AER LIQ 80MCG/1 ACTUATION,3202364,CDM,250,RC,,,outpatient,,,81.94,61.46,,65.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.97,65.55,
NF-IRBESARTAN ORAL TABLET 150MG,3202365,CDM,250,RC,,,outpatient,,,11.36,8.52,,9.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.57,9.09,
NF-FLEBOGAMMA 10% DIF IV SOLN 100MG/1ML,3202369,CDM,250,RC,,,outpatient,,,37.24,27.93,,29.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.99,29.79,
NF-OXYCONTIN EXT-RELEASE TABLET 40MG,3202370,CDM,250,RC,,,outpatient,,,31.19,23.39,,24.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.55,24.95,
NF-RENA-VITE RX ORAL TABLET,3202371,CDM,250,RC,,,outpatient,,,1.63,1.22,,1.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.66,1.3,
NF-VEGETABLE POWDER,3202373,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-VALSARTAN AND HYDROCHLOROTHIAZIDE TAB,3202374,CDM,250,RC,,,outpatient,,,20.06,15.05,,16.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.07,16.05,
NF-CHLORPROMAZINE HCL TAB 10MG,3202375,CDM,250,RC,,,outpatient,,,2.59,1.94,,2.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.04,2.07,
NF-AZO CRANBERRY ORAL TABLET,3202376,CDM,250,RC,,,outpatient,,,0.45,0.34,,0.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.18,0.36,
NF-GARLIC CAPSULE 500MG,3202377,CDM,250,RC,,,outpatient,,,0.27,0.2,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-FLUOCINOLONE   CRE  0.01%,3202378,CDM,250,RC,,,outpatient,,,11.07,8.3,,8.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.45,8.86,
NF-CARBAMIDE PEROXIDE OTIC SOLUTION 6.5%,3202380,CDM,250,RC,,,outpatient,,,1.72,1.29,,1.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.69,1.38,
NF-DOK PLUS TABLETS,3202381,CDM,250,RC,,,outpatient,,,1.41,1.06,,1.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.57,1.13,
NF-PYRAZINAMIDE TAB 500MG,3202382,CDM,250,RC,,,outpatient,,,3.46,2.6,,2.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.39,2.77,
NF-ETHAMBUTOL HCL TAB 400MG,3202383,CDM,250,RC,,,outpatient,,,6.33,4.75,,5.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.55,5.06,
NF-ALLEGRA-D 12 HOUR TAB ER 60MG-120MG,3202384,CDM,250,RC,,,outpatient,,,9.19,6.89,,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.7,7.35,
NF-FLUVOXAMINE MALEATE CAP ER 150MG,3202385,CDM,250,RC,,,outpatient,,,23.98,17.99,,19.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.65,19.18,
MYAMBUTOL TABLET 400MG,3202387,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PYRAZINAMIDE TABLET 500MG,3202388,CDM,637,RC,,,outpatient,,,2.76,2.07,,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.11,2.21,
NF-DISULFIRAM ORAL TABLET  500MG,3202389,CDM,250,RC,,,outpatient,,,24.15,18.11,,19.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.72,19.32,
NF-BISOPROLOL-HYDROCHLOROTHIAZIDE TAB 5M,3202390,CDM,250,RC,,,outpatient,,,1.22,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
NF-ORTHO-CYCLEN 35MCG-0.25MG ORAL TABLET,3202391,CDM,250,RC,,,outpatient,,,7.6,5.7,,6.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.06,6.08,
NF-METHIMAZOLE 5MG ORAL TABLET,3202392,CDM,250,RC,,,outpatient,,,2.92,2.19,,2.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,2.34,
NF-MAG-CAL MEGA 133.3MG-266.7MG ORAL TAB,3202393,CDM,250,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
NF-FENOFIBRATE ORAL TABLET 160MG,3202394,CDM,250,RC,,,outpatient,,,22.83,17.12,,18.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.19,18.26,
"NF-NIACIN 1000MG ORAL TABLET, EXTENDED R",3202395,CDM,250,RC,,,outpatient,,,27.73,20.8,,22.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.16,22.18,
NF-CANDESARTAN CILEXETIL-HYDROCHLOROTHIA,3202396,CDM,250,RC,,,outpatient,,,16.69,12.52,,13.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,13.35,
NF-HYDRALAZINE HCL 50MG ORAL TABLET,3202397,CDM,637,RC,,,outpatient,,,2.08,1.56,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.84,1.66,
"NF-VITAMIN D3 1000IU ORAL CAPSULE, LIQUI",3202398,CDM,250,RC,,,outpatient,,,0.33,0.25,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-METHADONE HCL CONCENTRATE 10MG/ML,3202399,CDM,250,RC,,,outpatient,,,0.39,0.29,,0.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.31,
NF-ZOLOFT 25MG ORAL TABLET,3202400,CDM,637,RC,,,outpatient,,,30.04,22.53,,24.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.09,24.03,
NF-TYLENOL EXTRA STRENGTH 500MG ORAL CAP,3202401,CDM,637,RC,,,outpatient,,,0.35,0.26,,0.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.28,
NF-DOCUSATE SODIUM 100MG ORAL CAPSULE,3202403,CDM,637,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-KEPPRA 250MG ORAL TABLET,3202404,CDM,637,RC,,,outpatient,,,12.7,9.53,,10.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.11,10.16,
NF-N-ACETYL-L-CYSTEINE 600MG CAPSULE,3202405,CDM,250,RC,,,outpatient,,,2.33,1.75,,1.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.94,1.86,
NF-IMIPRAMINE HCL 10MG ORAL TABLET,3202406,CDM,250,RC,,,outpatient,,,1.59,1.19,,1.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.64,1.27,
NF-METHADONE HCL ORAL TABLET 10MG,3202407,CDM,250,RC,,,outpatient,,,0.55,0.41,,0.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.22,0.44,
NF-VITAMIN B COMPLEX ORAL CAPSULE,3202408,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-AMOXICILLIN 400MG/5ML ORAL POWDER FOR,3202409,CDM,250,RC,,,outpatient,,,0.36,0.27,,0.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.29,
NF-ACETAMINOPHEN-CODEINE PHOSPHATE 120MG,3202410,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
NF-PERCOCET ORAL TABLET 10MG-325MG,3202411,CDM,250,RC,,,outpatient,,,24.96,18.72,,19.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.04,19.97,
XRT SOLUTION 5ML,3202413,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
RIFAMPIN ORAL CAPSULE 150MG,3202415,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-PACERONE 200MG ORAL TABLET,3202416,CDM,250,RC,,,outpatient,,,26.09,19.57,,20.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.5,20.87,
NF-ADDERALL 12.5MG ORAL TABLET,3202417,CDM,250,RC,,,outpatient,,,20.45,15.34,,16.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.23,16.36,
NF-CALCIUM 600MG-200IU ORAL TABLET,3202418,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-BIEST-PROGESTERONE MULTIPLE ROUTES KI,3202420,CDM,250,RC,,,outpatient,,,28.26,21.2,,22.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.37,22.61,
NF-CRESTOR 40MG ORAL TABLET,3202421,CDM,250,RC,,,outpatient,,,20.53,15.4,,16.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.26,16.42,
NF-TOUJEO SUBCUTANEOUS SOLUTION 300U/1ML,3202422,CDM,250,RC,,,outpatient,,,331.01,248.26,,264.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.2,264.81,
NF-OMEGA-3 KRILL OIL 27MG-45MG-300MG-90M,3202423,CDM,250,RC,,,outpatient,,,1.33,1,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.06,
NF-DESMOPRESSIN ACETATE ORAL TABLET 0.2M,3202425,CDM,250,RC,,,outpatient,,,35.35,26.51,,28.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.22,28.28,
NF-IMMUNE GLOBULIN IV SOLN 50MG/1ML,3202427,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
NF-IMMUNE GLOBULIN IV SOLN 50MG/1ML,3202428,CDM,250,RC,,,outpatient,,,29.96,22.47,,23.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.06,23.97,
NF-IMMUNE GLOBULIN IV SOLN 50MG/1ML,3202429,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
NF-IMMUNE GLOBULIN IV SOLN 50MG/1ML,3202430,CDM,250,RC,,,outpatient,,,29.96,22.47,,23.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.06,23.97,
NF-HYDROXYZINE HCL 50MG ORAL TABLET,3202431,CDM,250,RC,,,outpatient,,,3.94,2.96,,3.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.59,3.15,
NF-DEPO-TESTOSTERONE 100MG/1ML INTRAMUSC,3202432,CDM,250,RC,,,outpatient,,,28.93,21.7,,23.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.64,23.14,
NF-CYANOCOBALAMIN 1000MCG/1ML INJECTION,3202433,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-COUMADIN 2MG ORAL TABLET,3202434,CDM,250,RC,,,outpatient,,,4.11,3.08,,3.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.65,3.29,
NF-NEURONTIN 100MG ORAL CAPSULE,3202435,CDM,250,RC,,,outpatient,,,5.64,4.23,,4.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.51,
NF-DOCUSATE SODIUM AND SENNOSIDES 50MG-8,3202436,CDM,250,RC,,,outpatient,,,0.53,0.4,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-SEROQUEL 300MG ORAL TABLET,3202437,CDM,250,RC,,,outpatient,,,29.86,22.4,,23.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.02,23.89,
NF-DEXAMETHASONE 2MG ORAL TABLET,3202438,CDM,250,RC,,,outpatient,,,2.93,2.2,,2.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,2.34,
NF-EVISTA 60MG ORAL TABLET,3202439,CDM,250,RC,,,outpatient,,,23.63,17.72,,18.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.51,18.9,
NF-HYDROCHLOROTHIAZIDE 12.5MG ORAL CAPSU,3202440,CDM,250,RC,,,outpatient,,,1.23,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
"NF-PRILOSEC 40MG ORAL CAPSULE, DELAYED R",3202441,CDM,250,RC,,,outpatient,,,29.8,22.35,,23.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.99,23.84,
NF-VITAMIN C 1000MG ORAL TABLET,3202442,CDM,250,RC,,,outpatient,,,0.58,0.44,,0.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.46,
NF-MAGNESIUM OXIDE 200MG ORAL TABLET,3202443,CDM,250,RC,,,outpatient,,,0.45,0.34,,0.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.18,0.36,
NF-BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 20,3202444,CDM,250,RC,,,outpatient,,,3.89,2.92,,3.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.57,3.11,
NF-NEXIUM CAP DR 40MG,3202445,CDM,250,RC,,,outpatient,,,19.65,14.74,,15.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.91,15.72,
"NF-NEXIUM 40MG ORAL CAPSULE, DELAYED REL",3202446,CDM,250,RC,,,outpatient,,,98.25,73.69,,78.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.54,78.6,
NF-CALTRATE 600 600MG ORAL TABLET,3202447,CDM,250,RC,,,outpatient,,,0.53,0.4,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-FAMOTIDINE 40MG ORAL TABLET,3202448,CDM,250,RC,,,outpatient,,,17.32,12.99,,13.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.97,13.86,
NF-XYZAL 5MG ORAL TABLET,3202450,CDM,250,RC,,,outpatient,,,15.28,11.46,,12.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.15,12.22,
NF-FENOFIBRATE CAP 134MG,3202451,CDM,250,RC,,,outpatient,,,7.25,5.44,,5.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.92,5.8,
NF-ALPRAZOLAM ORAL TAB ER 2MG,3202452,CDM,250,RC,,,outpatient,,,13.79,10.34,,11.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.55,11.03,
PINK BISMUTH CHEWABLE TAB 262MG,3202453,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-CORLANOR 5MG ORAL TABLET,3202454,CDM,250,RC,,,outpatient,,,27.75,20.81,,22.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.17,22.2,
NF-SPIRONOLACTONE 50MG ORAL TABLET,3202455,CDM,250,RC,,,outpatient,,,3.62,2.72,,2.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.46,2.9,
"NF-OMEGA-3 KRILL OIL ORAL CAPSULE, LIQUI",3202456,CDM,250,RC,,,outpatient,,,1.06,0.8,,0.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.43,0.85,
NF-INVOKAMET 150MG-1000MG ORAL TABLET,3202457,CDM,250,RC,,,outpatient,,,25.37,19.03,,20.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.21,20.3,
"NF-VITAMIN E 1000IU ORAL CAPSULE, LIQUID",3202458,CDM,250,RC,,,outpatient,,,1.21,0.91,,0.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.97,
NF-PRADAXA 150MG ORAL CAPSULE,3202459,CDM,250,RC,,,outpatient,,,23.29,17.47,,18.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.37,18.63,
NF-SOTALOL 80MG ORAL TABLET,3202460,CDM,250,RC,,,outpatient,,,18.96,14.22,,15.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.63,15.17,
NF-SUCRALFATE 1GM ORAL TABLET,3202461,CDM,250,RC,,,outpatient,,,2.52,1.89,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2.02,
NF-GOOD NEIGHBOR PHARMACY GLUCOSAMINE CH,3202462,CDM,250,RC,,,outpatient,,,0.6,0.45,,0.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.24,0.48,
NF-ARTIFICIAL TEARS OPHTHALMIC SOLUTION,3202463,CDM,250,RC,,,outpatient,,,1.72,1.29,,1.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.69,1.38,
NF-TRAMADOL HCL 50MG ORAL TABLET,3202464,CDM,250,RC,,,outpatient,,,5.75,4.31,,4.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.31,4.6,
NF-HYDRALAZINE HCL 50MG ORAL TABLET,3202465,CDM,250,RC,,,outpatient,,,2.08,1.56,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.84,1.66,
NF-CO-Q-10 ORAL LIQUID CAPSULE 200MG,3202466,CDM,250,RC,,,outpatient,,,1.44,1.08,,1.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.58,1.15,
NF-POTASSIUM GLUCONATE TABLET 595MG,3202467,CDM,250,RC,,,outpatient,,,0.24,0.18,,0.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.19,
NF-BIOTIN 300MCG ORAL TABLET,3202468,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-ZINC 10MG ORAL TABLET,3202469,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-LACTULOSE 10GM/15ML ORAL SOLUTION,3202470,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-CEREFOLIN NAC 600MG-5.6MG-2MG ORAL TA,3202471,CDM,250,RC,,,outpatient,,,14.61,10.96,,11.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.88,11.69,
NF-OCUFLOX 0.3% OPHTHALMIC SOLUTION,3202473,CDM,250,RC,,,outpatient,,,83.03,62.27,,66.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.41,66.42,
"NF-OMEPRAZOLE 20MG ORAL TABLET, DELAYED",3202474,CDM,250,RC,,,outpatient,,,32.51,24.38,,26.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.08,26.01,
"NF-POTASSIUM CHLORIDE 20MEQ ORAL TABLET,",3202476,CDM,250,RC,,,outpatient,,,2.32,1.74,,1.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.86,
NF-METFORMIN HCL 500MG ORAL TABLET,3202477,CDM,250,RC,,,outpatient,,,2.59,1.94,,2.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.04,2.07,
NF-TUDORZA PRESSAIR INH AER PWD 400MCG/1,3202478,CDM,250,RC,,,outpatient,,,624.71,468.53,,499.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,251.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,312.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,343.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,251.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,499.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,251.38,499.77,
NF-TOUJEO SUBCUTANEOUS SOLUTION 300U/1ML,3202479,CDM,250,RC,,,outpatient,,,331.01,248.26,,264.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.2,264.81,
NF-LISINOPRIL 40MG ORAL TABLET,3202480,CDM,250,RC,,,outpatient,,,5.76,4.32,,4.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.32,4.61,
NF-CLIMARA TRANSDERM PATCH 0.05MG/24HRS,3202482,CDM,250,RC,,,outpatient,,,115.37,86.53,,92.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.42,92.3,
NF-SAPHRIS SL TAB 10MG,3202483,CDM,250,RC,,,outpatient,,,51.04,38.28,,40.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.54,40.83,
NF-SEROQUEL ORAL TABLET 300MG,3202484,CDM,250,RC,,,outpatient,,,39.12,29.34,,31.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.74,31.3,
NF-RISPERDAL ORAL TABLET 3MG,3202485,CDM,250,RC,,,outpatient,,,57.68,43.26,,46.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.21,46.14,
"NF-PREVACID 30MG ORAL CAPSULE, DELAYED R",3202491,CDM,250,RC,,,outpatient,,,42.81,32.11,,34.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.23,34.25,
NF-MIRAPEX 0.25MG ORAL TABLET,3202492,CDM,637,RC,,,outpatient,,,14.44,10.83,,11.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.81,11.55,
NF-ZINC SULFATE 220MG ORAL CAPSULE,3202493,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-MACROBID 100MG ORAL CAPSULE,3202494,CDM,250,RC,,,outpatient,,,15.83,11.87,,12.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.37,12.66,
NF-LEVOTHYROXINE SODIUM 175MCG ORAL TABL,3202495,CDM,637,RC,,,outpatient,,,2.04,1.53,,1.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.63,
NF-OMEGA-3 ORAL CAPSULE 1000MG-5IU,3202496,CDM,250,RC,,,outpatient,,,0.24,0.18,,0.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.19,
NF-AZOR 5MG-20MG ORAL TABLET,3202497,CDM,250,RC,,,outpatient,,,26.86,20.15,,21.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.81,21.49,
NF-OLANZAPINE 15MG ORAL TABLET,3202498,CDM,250,RC,,,outpatient,,,112.73,84.55,,90.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.36,90.18,
NF-CLONAZEPAM 1MG ORAL TABLET,3202499,CDM,250,RC,,,outpatient,,,3.16,2.37,,2.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.27,2.53,
NF-TRIAMCINOLONE ACETONIDE 0.1% TOPICAL,3202501,CDM,250,RC,,,outpatient,,,2.62,1.97,,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.05,2.1,
NF-LUNESTA ORAL TABLET 3MG,3202504,CDM,250,RC,,,outpatient,,,19.91,14.93,,15.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.01,15.93,
NF-MILK OF MAGNESIA ORAL SUSP 1200MG/15M,3202505,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-OMEPRAZOLE CAP DR 40MG,3202506,CDM,250,RC,,,outpatient,,,27.37,20.53,,21.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.01,21.9,
NF-LANSOPRAZOLE CAP DELAYED RELEASE 30MG,3202508,CDM,250,RC,,,outpatient,,,21.79,16.34,,17.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.77,17.43,
NF-BROMOCRIPTINE MESYLATE 2.5MG ORAL TAB,3202509,CDM,250,RC,,,outpatient,,,23.13,17.35,,18.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.31,18.5,
NF-TRIAZOLAM 0.25MG ORAL TABLET,3202510,CDM,250,RC,,,outpatient,,,11.57,8.68,,9.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.66,9.26,
"NF-VITAMIN E 1000 IU ORAL CAPSULE, LIQUI",3202511,CDM,250,RC,,,outpatient,,,0.4,0.3,,0.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.32,
NF-RITE AID POTASSIUM GLUCONATE 99 MG OR,3202513,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-LISINOPRIL 5MG ORAL TABLET,3202514,CDM,250,RC,,,outpatient,,,3.52,2.64,,2.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.42,2.82,
"NF-COQ10 100 MG-1 IU ORAL CAPSULE, LIQUI",3202515,CDM,250,RC,,,outpatient,,,0.82,0.62,,0.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.33,0.66,
NF-NORTRIPTYLINE HCL CAP 50MG,3202516,CDM,250,RC,,,outpatient,,,1.28,0.96,,1.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.52,1.02,
NF-GLIPIZIDE ER ORAL TAB ER 2.5MG,3202517,CDM,250,RC,,,outpatient,,,4.6,3.45,,3.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.85,3.68,
VICTOZA SUBCU 6MG/1ML (2),3202518,CDM,637,RC,,,outpatient,,,512.78,384.59,,410.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,410.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.34,410.22,
NF-ADDERALL XR CAP ER 25MG,3202519,CDM,250,RC,,,outpatient,,,31.63,23.72,,25.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.73,25.3,
NF-LIALDA TAB DR 1.2GM,3202520,CDM,250,RC,,,outpatient,,,32.39,24.29,,25.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.03,25.91,
NF-MERCAPTOPURINE ORAL TABLET 50MG,3202521,CDM,250,RC,,,outpatient,,,27.94,20.96,,22.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.24,22.35,
NF-OMEPRAZOLE CAP DR 40MG,3202522,CDM,250,RC,,,outpatient,,,27.36,20.52,,21.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.01,21.89,
NF-ZOCOR 40MG ORAL TABLET,3202523,CDM,250,RC,,,outpatient,,,19.42,14.57,,15.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.81,15.54,
NF-FARXIGA 10MG ORAL TABLET,3202525,CDM,250,RC,,,outpatient,,,46.18,34.64,,36.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.58,36.94,
NF-BRILINTA ORAL TABLET 90MG,3202526,CDM,250,RC,,,outpatient,,,21.12,15.84,,16.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.5,16.9,
NF-OTEZLA ORAL TABLET 30MG,3202527,CDM,250,RC,,,outpatient,,,164.38,123.29,,131.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.15,131.5,
NF-BUSPIRONE 10MG ORAL TABLET,3202528,CDM,250,RC,,,outpatient,,,4.63,3.47,,3.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.86,3.7,
NF-CHLORPROMAZINE HCL 200MG ORAL TABLET,3202529,CDM,250,RC,,,outpatient,,,98.11,73.58,,78.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.48,78.49,
"NF-VERAPAMIL HCL 180MG ORAL TABLET, EXTE",3202530,CDM,637,RC,,,outpatient,,,12.95,9.71,,10.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.21,10.36,
NF-TERAZOSIN HCL 10MG ORAL CAPSULE,3202531,CDM,637,RC,,,outpatient,,,5.82,4.37,,4.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.34,4.66,
NF-PREDNISOLONE ACETATE 1% OPHTHALMIC SU,3202532,CDM,637,RC,,,outpatient,,,8.41,6.31,,6.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.38,6.73,
NF-ULORIC ORAL TABLET 40MG,3202533,CDM,250,RC,,,outpatient,,,38.28,28.71,,30.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.4,30.62,
NF-RISPERDAL ORAL TABLET 0.5MG,3202534,CDM,250,RC,,,outpatient,,,15.28,11.46,,12.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.15,12.22,
NF-FARXIGA TAB 5MG,3202536,CDM,250,RC,,,outpatient,,,46.18,34.64,,36.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.58,36.94,
NF-CARAFATE TABLET 1GM,3202537,CDM,250,RC,,,outpatient,,,4.24,3.18,,3.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.39,
NF-MIRTAZAPINE 45MG ORAL TABLET,3202538,CDM,250,RC,,,outpatient,,,10.55,7.91,,8.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.25,8.44,
NF-SPIRIVA RESPIMAT 2.5MCG/1ACT INHALATI,3202539,CDM,250,RC,,,outpatient,,,350.41,262.81,,280.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,141,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,141,280.33,
NF-FLEBOGAMMA 5% DIF IV SOLN 50MG/ML,3202540,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
NF-FLEBOGAMMA 5% DIF IV SOLN 50MG/ML,3202541,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
NF-FLEBOGAMMA 5% DIF IV SOLN 50MG/ML,3202542,CDM,250,RC,,,outpatient,,,18.62,13.97,,14.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,14.9,
NF-ORENCIA INTRAVENOUS PWD FOR SOLN 250M,3202543,CDM,250,RC,,,outpatient,,,3493.69,2620.27,,2794.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1405.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1746.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1746.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1746.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1746.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1921.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2794.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2620.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1405.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2794.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2620.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2794.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2794.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2794.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1405.86,2794.95,
NF-MELATONIN TABLET 0.3MG,3202544,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-NEXIUM CAP DR 40MG,3202545,CDM,250,RC,,,outpatient,,,45.55,34.16,,36.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.33,36.44,
NF-RESTASIS OPHTH EMULSION 0.05%,3202546,CDM,250,RC,,,outpatient,,,28.73,21.55,,22.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.56,22.98,
NF-IRON TABLET 65MG,3202547,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-BUTALBITAL COMPOUND 50MG-325MG-40MG O,3202548,CDM,250,RC,,,outpatient,,,2.36,1.77,,1.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.89,
NF-FIORINAL 50MG-325MG-40MG ORAL TABLET,3202549,CDM,250,RC,,,outpatient,,,5.44,4.08,,4.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,4.35,
NF-CALCIUM 600MG ORAL TABLET,3202550,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-ADVAIR DISKUS 250/50 0.25MG-0.05MG/1I,3202551,CDM,250,RC,,,outpatient,,,21.59,16.19,,17.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.69,17.27,
NF-VENTOLIN HFA 0.09MG/1INH INHALATION A,3202553,CDM,250,RC,,,outpatient,,,11.79,8.84,,9.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.74,9.43,
NF-WATER FOR IRRIGATION IRRIGATION SOLUT,3202554,CDM,250,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-ATENOLOL 25MG ORAL TABLET,3202556,CDM,637,RC,,,outpatient,,,2.96,2.22,,2.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.19,2.37,
NF-FERROUS SULFATE 325MG ORAL TABLET,3202557,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-METFORMIN HCL 1000MG ORAL TABLET,3202558,CDM,250,RC,,,outpatient,,,3.33,2.5,,2.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.34,2.66,
NF-KEPPRA 1000MG ORAL TABLET,3202559,CDM,250,RC,,,outpatient,,,61.52,46.14,,49.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.76,49.22,
NF-FERROUS GLUCONATE 324MG ORAL TABLET,3202560,CDM,250,RC,,,outpatient,,,0.41,0.31,,0.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.33,
NF-SUCRALFATE 1GM ORAL TABLET,3202561,CDM,250,RC,,,outpatient,,,3.52,2.64,,2.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.42,2.82,
NF-QVAR 0.08MG/1 ACTUATION INHALATION AE,3202562,CDM,250,RC,,,outpatient,,,89.09,66.82,,71.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.85,71.27,
NF-LYRICA 150MG ORAL CAPSULE,3202563,CDM,250,RC,,,outpatient,,,16.28,12.21,,13.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.55,13.02,
NF-ESGIC 50MG-325MG-40MG ORAL CAPSULE,3202564,CDM,250,RC,,,outpatient,,,9.07,6.8,,7.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.65,7.26,
NF-MAXITROL OPHTH SUSPENSION,3202565,CDM,250,RC,,,outpatient,,,5.65,4.24,,4.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.52,
NF-BUSPIRONE 10MG ORAL TABLET,3202566,CDM,250,RC,,,outpatient,,,7.33,5.5,,5.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.95,5.86,
NF-DICLOFENAC SODIUM GEL 1%,3202567,CDM,250,RC,,,outpatient,,,1.83,1.37,,1.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.74,1.46,
NF-GEODON 60MG ORAL CAPSULE,3202568,CDM,250,RC,,,outpatient,,,72.25,54.19,,57.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.07,57.8,
NF-GEODON 80MG ORAL CAPSULE,3202569,CDM,250,RC,,,outpatient,,,72.25,54.19,,57.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.07,57.8,
NF-CYTOTEC 100MCG ORAL TABLET,3202570,CDM,250,RC,,,outpatient,,,10.7,8.03,,8.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.31,8.56,
NF-SODIUM BICARBONATE 325 MG ORAL TABLET,3202571,CDM,250,RC,,,outpatient,,,0.17,0.13,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-PHENOBARBITAL 60MG ORAL TABLET,3202572,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-CALCIUM ANTACID ULTR CHEWABLE TAB 100,3202573,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
NF-EDARBYCLOR ORAL TABLET 40MG-25MG,3202574,CDM,250,RC,,,outpatient,,,22.72,17.04,,18.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.14,18.18,
NF-AMLODIPINE BESYLATE-ATORVASTATIN CALC,3202575,CDM,250,RC,,,outpatient,,,34.67,26,,27.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.95,27.74,
NF-VITAMIN B COMPLEX WITH B12 ORAL TABLE,3202576,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
PR US FETAL AGE,4110013,CDM,972,RC,7681526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-NIASPAN EXTENDED-RELEASE TABLET 1000M,3202578,CDM,250,RC,,,outpatient,,,29.13,21.85,,23.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.72,23.3,
NF-REMERON 30MG ORAL TABLET,3202579,CDM,250,RC,,,outpatient,,,22.81,17.11,,18.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.18,18.25,
NF-MEMANTINE HCL ORAL TABLET 5MG,3202582,CDM,250,RC,,,outpatient,,,22.56,16.92,,18.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.08,18.05,
NF-CLOBETASOL PROPIONATE CREAM 0.05%,3202583,CDM,250,RC,,,outpatient,,,28.3,21.23,,22.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.39,22.64,
NF-KLONOPIN 1MG ORAL TABLET,3202584,CDM,250,RC,,,outpatient,,,11.29,8.47,,9.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.54,9.03,
NF-REGLAN 10MG ORAL TABLET,3202585,CDM,250,RC,,,outpatient,,,9.19,6.89,,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.7,7.35,
NF-FENOFIBRATE 160MG ORAL TABLET,3202586,CDM,250,RC,,,outpatient,,,8.79,6.59,,7.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.54,7.03,
NF-BENAZEPRIL 10MG ORAL TABLET,3202587,CDM,250,RC,,,outpatient,,,3.66,2.75,,2.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.47,2.93,
NF-LISINOPRIL 5 MG ORAL TABLET,3202588,CDM,637,RC,,,outpatient,,,1.38,1.04,,1.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.1,
NF-LAMOTRIGINE 150MG ORAL TABLET,3202589,CDM,250,RC,,,outpatient,,,19.27,14.45,,15.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.75,15.42,
"NF-CLONAZEPAM 1MG ORAL TABLET, DISINTEGR",3202590,CDM,250,RC,,,outpatient,,,5.48,4.11,,4.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.38,
NF-LEVETIRACETAM 1000MG ORAL TABLET,3202591,CDM,250,RC,,,outpatient,,,17.61,13.21,,14.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,14.09,
NF-VALIUM 10MG ORAL TABLET,3202592,CDM,250,RC,,,outpatient,,,0.82,0.62,,0.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.33,0.66,
NF-CALCIUM GLUCONATE TABLET 500MG,3202593,CDM,250,RC,,,outpatient,,,0.91,0.68,,0.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.37,0.73,
NF-GERITOL COMPLETE TAB,3202594,CDM,250,RC,,,outpatient,,,0.33,0.25,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-OMEPRAZOLE CAP DR 20MG,3202595,CDM,250,RC,,,outpatient,,,19.68,14.76,,15.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.92,15.74,
NF-JANUVIA ORAL TABLET 25MG,3202596,CDM,250,RC,,,outpatient,,,48.93,36.7,,39.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.69,39.14,
PR US FETAL AGE (FOLLOW-UP/REPEAT),4110014,CDM,972,RC,7681626,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-ISOSORBIDE MONONITRATE ORAL TAB ER 12,3202598,CDM,250,RC,,,outpatient,,,10.86,8.15,,8.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.37,8.69,
NF-HYDRALAZINE HCL ORAL TABLET 100MG,3202599,CDM,250,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
NF-GAS RELIEF EXTRA STRENGTH CAPSULE 125,3202600,CDM,250,RC,,,outpatient,,,0.57,0.43,,0.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.46,
NF-NITRO-DUR TRANSDERM PATCH ER 0.8MG/1H,3202601,CDM,250,RC,,,outpatient,,,23.84,17.88,,19.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.59,19.07,
NF-VITAMIN B-6 ORAL TABLET 100MG,3202603,CDM,250,RC,,,outpatient,,,0.65,0.49,,0.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.26,0.52,
NF-CEPACOL SORE THROAT \& COUGH 7.5 MG-5,3202604,CDM,250,RC,,,outpatient,,,0.67,0.5,,0.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.27,0.54,
NF-BACLOFEN 20MG ORAL TABLET,3202605,CDM,250,RC,,,outpatient,,,18.98,14.24,,15.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.64,15.18,
NF-MILK OF MAGNESIA 400MG/5ML ORAL SUSPE,3202606,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
NF-BENADRYL ALLERGY 25MG ORAL TABLET,3202607,CDM,250,RC,,,outpatient,,,0.69,0.52,,0.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.28,0.55,
NF-MULTIPLE VITAMINS ORAL TABLET,3202608,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-PROSTATE 140 MG ORAL CAPSULE,3202609,CDM,250,RC,,,outpatient,,,0.19,0.14,,0.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.15,
"NF-VITAMIN C 500MG ORAL CAPSULE, EXTENDE",3202610,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
PR US GALLBLADDER,4110015,CDM,972,RC,7670526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-BIOTENE DRY MOUTH MOUTHWASH MM SOLUTI,3202612,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-AMLODIPINE BESYLATE-BENAZEPRIL HCL 10,3202613,CDM,250,RC,,,outpatient,,,18.12,13.59,,14.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.29,14.5,
NF-DOXYCYCLINE 50MG ORAL CAPSULE,3202614,CDM,250,RC,,,outpatient,,,5.37,4.03,,4.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.16,4.3,
NF-FLAVOXATE HCL 100MG ORAL TABLET,3202615,CDM,250,RC,,,outpatient,,,5.41,4.06,,4.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.18,4.33,
CLOTRIMAZOLE/BETAMETHASONE CREAM 15 gm,3202616,CDM,637,RC,,,outpatient,,,17.6,13.2,,14.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.08,14.08,
Clotrimazole/Betameth Dipr. Cr. 15 g,3202617,CDM,250,RC,,,outpatient,,,17.6,13.2,,14.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.08,14.08,
NF-QVAR INH/NEB AER LIQ 0.04MG/1 ACTUATI,3202619,CDM,250,RC,,,outpatient,,,71.19,53.39,,56.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.65,56.95,
NF-GAS FREE EXTRA STRENGTH 125 MG ORAL C,3202620,CDM,250,RC,,,outpatient,,,0.48,0.36,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-CONJUGATED ESTROGENS 0.625MG ORAL TAB,3202621,CDM,250,RC,,,outpatient,,,0.91,0.68,,0.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.37,0.73,
NF-ASMANEX TWISTHALER PWD 110MCG/1ACT,3202622,CDM,250,RC,,,outpatient,,,687.02,515.27,,549.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,276.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,343.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,343.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,343.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,343.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,377.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,276.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,515.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,549.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,276.46,549.62,
NF-FOLIC ACID ORAL TABLET 0.8MG,3202623,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-PRILOSEC ORAL CAPSULE DR 20MG,3202624,CDM,250,RC,,,outpatient,,,23.51,17.63,,18.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,18.81,
NF-PROAIR HFA AER PWD 0.09MG/1ACT,3202625,CDM,250,RC,,,outpatient,,,15.98,11.99,,12.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.43,12.78,
NF-SELENIUM CAPSULE 200MCG,3202626,CDM,250,RC,,,outpatient,,,0.24,0.18,,0.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.19,
NF-NAMENDA XR CAP ER 28MG,3202627,CDM,250,RC,,,outpatient,,,47.67,35.75,,38.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.18,38.14,
NF-METOPROLOL SUCCINATE 50MG ORAL TABLET,3202628,CDM,250,RC,,,outpatient,,,4.33,3.25,,3.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.74,3.46,
NF-FOLIC ACID 0.8 MG ORAL TABLET,3202629,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-ESTRADIOL 0.1MG/24HR TRANSDERMAL PATC,3202630,CDM,250,RC,,,outpatient,,,85.87,64.4,,68.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.55,68.7,
NF-VITAMIN E CAPSULE 1000IU,3202631,CDM,250,RC,,,outpatient,,,0.57,0.43,,0.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.46,
NF-N.A.C. ORAL CAPSULE 500MG,3202632,CDM,250,RC,,,outpatient,,,0.48,0.36,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-DIOVAN HCT 320MG-12.5MG ORAL TABLET,3202633,CDM,250,RC,,,outpatient,,,35.51,26.63,,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.29,28.41,
NF-SYSTANE 0.4%-0.3% OPHTHALMIC SOLUTION,3202634,CDM,250,RC,,,outpatient,,,2.06,1.55,,1.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.83,1.65,
NF-METOPROLOL SUCCINATE 50MG ORAL TABLET,3202635,CDM,250,RC,,,outpatient,,,3.34,2.51,,2.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.34,2.67,
NF-PRILOSEC CAP DR 20MG,3202636,CDM,250,RC,,,outpatient,,,23.51,17.63,,18.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,18.81,
NF-CALCIUM CARBONATE ORAL TABLET 600MG,3202637,CDM,250,RC,,,outpatient,,,1.22,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
PR US LIVER,4110019,CDM,972,RC,7670526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
ELIQUIS ORAL TABLET 2.5MG,3202640,CDM,637,RC,,,outpatient,,,7.92,5.94,,6.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.19,6.34,
NF-VYTORIN ORAL TABLET 10MG-40MG,3202641,CDM,250,RC,,,outpatient,,,34.69,26.02,,27.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.96,27.75,
NF-UROCIT-K 10 TAB ER 10MEQ,3202642,CDM,250,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
NF-POTASSIUM CITRATE ORAL TAB ER 10MEQ,3202643,CDM,250,RC,,,outpatient,,,2.05,1.54,,1.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.64,
NF-STELARA 90MG/1ML SUBCUTANEOUS SOLUTIO,3202644,CDM,250,RC,,,outpatient,,,72725.05,54543.79,,58180.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29264.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36362.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36362.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36362.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36362.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39998.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58180.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54543.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54543.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54543.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54543.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29264.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29264.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58180.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54543.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58180.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58180.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29264.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,58180.04,
"NF-OMEPRAZOLE 20MG ORAL CAPSULE, DELAYED",3202646,CDM,250,RC,,,outpatient,,,12.48,9.36,,9.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.02,9.98,
NF-VITAMIN B12 1000 MCG SUBLINGUAL TABLE,3202647,CDM,250,RC,,,outpatient,,,0.48,0.36,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-FENOFIBRATE 48MG ORAL TABLET,3202648,CDM,250,RC,,,outpatient,,,7.07,5.3,,5.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.84,5.66,
NF-ELIQUIS ORAL TABLET 2.5MG,3202649,CDM,250,RC,,,outpatient,,,24.68,18.51,,19.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.93,19.74,
NF-ELIQUIS ORAL TABLET 2.5MG,3202650,CDM,250,RC,,,outpatient,,,24.68,18.51,,19.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.93,19.74,
NF-TASIGNA ORAL CAPSULE 150MG,3202652,CDM,250,RC,,,outpatient,,,383.35,287.51,,306.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.26,306.68,
NF-CITALOPRAM 40MG ORAL TABLET,3202653,CDM,637,RC,,,outpatient,,,9.82,7.37,,7.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.95,7.86,
NF-PERCOCET 10MG-325MG ORAL TABLET,3202654,CDM,250,RC,,,outpatient,,,54.39,40.79,,43.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.89,43.51,
NF-ADVAIR DISKUS 100/50 0.1MG-0.05MG/1IN,3202656,CDM,250,RC,,,outpatient,,,37.85,28.39,,30.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.23,30.28,
NF-OMEGA-3 KRILL OIL ORAL LIQUID CAPSULE,3202657,CDM,250,RC,,,outpatient,,,1.33,1,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.06,
NF-PRILOSEC CAP DR 20MG,3202658,CDM,250,RC,,,outpatient,,,23.51,17.63,,18.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,18.81,
NF-SYSTANE OPHTH SOLUTION,3202659,CDM,250,RC,,,outpatient,,,2.16,1.62,,1.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.87,1.73,
CLINIMIX E 4.25/25 INJECTION,3202660,CDM,250,RC,,,outpatient,,,153.55,115.16,,122.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.79,122.84,
NF-IMMUNE GLOBULIN INJ SOLN 100MG/1ML,3202661,CDM,250,RC,,,outpatient,,,45.01,33.76,,36.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36.01,
NF-NEXIUM CAP DR 40MG,3202662,CDM,250,RC,,,outpatient,,,35.14,26.36,,28.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.14,28.11,
NF-NOVOLOG FLEXPEN SQ SOLN 100U/ML,3202663,CDM,250,RC,,,outpatient,,,127.75,95.81,,102.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.41,102.2,
NF-DEPLIN 15 CAP 15MG-90.314MG,3202664,CDM,250,RC,,,outpatient,,,16.92,12.69,,13.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.81,13.54,
NF-ENTECAVIR ORAL TABLET 1MG,3202666,CDM,250,RC,,,outpatient,,,164.4,123.3,,131.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.15,131.52,
NF-METHOTREXATE 2.5MG ORAL TABLET,3202667,CDM,250,RC,,,outpatient,,,13.19,9.89,,10.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.31,10.55,
"NF-MORPHINE SULFATE 10 MG ORAL CAPSULE,",3202668,CDM,250,RC,,,outpatient,,,17.51,13.13,,14.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.05,14.01,
NF-ALBUTEROL 0.09MG/ACTUATION INHALATION,3202669,CDM,250,RC,,,outpatient,,,12.72,9.54,,10.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.12,10.18,
NF-POTASSIUM GLUCONATE 595 MG ORAL TABLE,3202670,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-MORPHINE SULFATE ORAL SOLUTION 20MG/1,3202671,CDM,250,RC,,,outpatient,,,2.54,1.91,,2.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.03,
NF-CITALOPRAM 40MG ORAL TABLET,3202672,CDM,250,RC,,,outpatient,,,0.53,0.4,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-KEPPRA 1000MG ORAL TABLET,3202673,CDM,250,RC,,,outpatient,,,30.14,22.61,,24.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.13,24.11,
NF-HUMULIN R 100U/1ML INJECTION SOLUTION,3202674,CDM,250,RC,,,outpatient,,,30.08,22.56,,24.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.1,24.06,
NF-FENOFIBRATE 134MG ORAL CAPSULE,3202675,CDM,250,RC,,,outpatient,,,7.25,5.44,,5.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.92,5.8,
NF-DEPAKENE CAPSULE 250MG,3202676,CDM,250,RC,,,outpatient,,,18.44,13.83,,14.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.42,14.75,
NF-XANAX 1MG ORAL TABLET,3202677,CDM,250,RC,,,outpatient,,,17.96,13.47,,14.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.23,14.37,
NF-ASMANEX TWIST 0.22MG/ACTUATION INHALA,3202678,CDM,250,RC,,,outpatient,,,683.91,512.93,,547.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,341.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,376.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,547.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,275.21,547.13,
NF-LIPITOR 80MG ORAL TABLET,3202679,CDM,250,RC,,,outpatient,,,40.26,30.2,,32.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.2,32.21,
NF-FERROUS GLUCONATE TAB 324MG,3202680,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-LYRICA CAP 150MG,3202681,CDM,250,RC,,,outpatient,,,23.33,17.5,,18.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.39,18.66,
"NF-OMEPRAZOLE 40MG ORAL CAPSULE, DELAYED",3202682,CDM,250,RC,,,outpatient,,,27.37,20.53,,21.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.01,21.9,
NF-TRAMADOL HCL 50MG ORAL TABLET,3202683,CDM,250,RC,,,outpatient,,,5.99,4.49,,4.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.79,
NF-MULTIVITAMIN WITH IRON ORAL TABLET,3202684,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-ACETYLCYSTEINE 20% INHALATION SOLUTIO,3202685,CDM,250,RC,,,outpatient,,,3.02,2.27,,2.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.22,2.42,
NF-TIMOLOL MALEATE 0.5% OPHTHALMIC GEL-F,3202686,CDM,250,RC,,,outpatient,,,68.22,51.17,,54.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.45,54.58,
NF-DOCUSATE SODIUM 100MG ORAL CAPSULE,3202687,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-CLOBETASOL PROPIONATE 0.05% TOPICAL A,3202688,CDM,250,RC,,,outpatient,,,3.79,2.84,,3.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.53,3.03,
NF-DICLOFENAC SODIUM 3% TOPICAL APPLICAT,3202689,CDM,250,RC,,,outpatient,,,43.64,32.73,,34.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.56,34.91,
NF-ASTRAGALUS EXTRACT POWDER,3202690,CDM,250,RC,,,outpatient,,,5.37,4.03,,4.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.16,4.3,
NF-L-CARNITINE POWDER,3202691,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-L-GLUTAMIC ACID HYDROCHLORIDE POWDER,3202692,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-ZINC ACETATE CAP 25MG,3202693,CDM,250,RC,,,outpatient,,,5.81,4.36,,4.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.34,4.65,
NF-AMLODIPINE -ATORVASTATIN TAB 5MG-10MG,3202694,CDM,250,RC,,,outpatient,,,25.34,19.01,,20.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.2,20.27,
NF-CADUET TAB 10MG-20MG,3202695,CDM,250,RC,,,outpatient,,,26.17,19.63,,20.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.53,20.94,
NF-LISINOPRIL 2.5MG ORAL TABLET,3202696,CDM,250,RC,,,outpatient,,,2.37,1.78,,1.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.9,
HUMALOG 5 UNITS INJ.,3202697,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-REQUIP ORAL TABLET 0.5MG,3202698,CDM,250,RC,,,outpatient,,,12.86,9.65,,10.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.17,10.29,
NF-STRESS TABS ORAL TABLET,3202699,CDM,250,RC,,,outpatient,,,0.37,0.28,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
NF-SPIRONOLACTONE 50MG ORAL TABLET,3202700,CDM,250,RC,,,outpatient,,,3.02,2.27,,2.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.22,2.42,
NF-INVOKANA 300MG ORAL TABLET,3202701,CDM,250,RC,,,outpatient,,,53.73,40.3,,42.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.62,42.98,
"NF-FERROUS SULFATE 325 MG ORAL TABLET, E",3202703,CDM,250,RC,,,outpatient,,,1.45,1.09,,1.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.58,1.16,
NF-VISION ORAL TABLET,3202704,CDM,250,RC,,,outpatient,,,0.38,0.29,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
NF-BENAZEPRIL 40MG ORAL TABLET,3202705,CDM,250,RC,,,outpatient,,,4.47,3.35,,3.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.8,3.58,
NF-POTASSIUM GLUCONATE 595 MG ORAL TABLE,3202706,CDM,250,RC,,,outpatient,,,0.23,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
MICROGESTIN 1/20 ORAL TABLET 20MCG-1MG,3202708,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5M,3202709,CDM,250,RC,,,outpatient,,,1.53,1.15,,1.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.62,1.22,
NF-METOPROLOL SUCCINATE 50MG ORAL TABLET,3202710,CDM,250,RC,,,outpatient,,,4.59,3.44,,3.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.85,3.67,
DULERA INH AER PWD 5MCG-100MCG/ACT,3202711,CDM,637,RC,,,outpatient,,,312.5,234.38,,250,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.75,250,
PR US NON VASCULAR EXTREMITY,4110020,CDM,972,RC,7688226,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-MIRAPEX 1MG ORAL TABLET,3202713,CDM,250,RC,,,outpatient,,,15.52,11.64,,12.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.25,12.42,
NF-MIRAPEX ORAL TABLET 1MG,3202714,CDM,250,RC,,,outpatient,,,8.23,6.17,,6.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.31,6.58,
NF-DOXEPIN HCL 100MG ORAL CAPSULE,3202715,CDM,637,RC,,,outpatient,,,6.64,4.98,,5.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.67,5.31,
NF-HYDROCHLOROTHIAZIDE 12.5MG ORAL TABLE,3202716,CDM,250,RC,,,outpatient,,,3.05,2.29,,2.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.23,2.44,
NF-FERROUS SULFATE 325MG ORAL TABLET,3202717,CDM,250,RC,,,outpatient,,,0.67,0.5,,0.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.27,0.54,
NF-VALTREX 500MG ORAL TABLET,3202718,CDM,250,RC,,,outpatient,,,40.24,30.18,,32.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.19,32.19,
NF-BENADRYL ALLERGY 25MG ORAL TABLET,3202719,CDM,250,RC,,,outpatient,,,0.55,0.41,,0.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.22,0.44,
NF-LIVALO ORAL TABLET 1MG,3202720,CDM,250,RC,,,outpatient,,,28.02,21.02,,22.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.28,22.42,
NF-SAW PALMETTO 450 MG ORAL CAPSULE,3202721,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
"NF-BUPROPION SR 100MG ORAL TABLET, EXTEN",3202722,CDM,637,RC,,,outpatient,,,10.19,7.64,,8.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.1,8.15,
NF-BENAZEPRIL 20MG ORAL TABLET,3202723,CDM,637,RC,,,outpatient,,,5.92,4.44,,4.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.38,4.74,
NF-ZOLPIDEM TARTRATE 10MG ORAL TABLET,3202724,CDM,637,RC,,,outpatient,,,23.59,17.69,,18.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.49,18.87,
"NF-APRISO 0.375GM ORAL CAPSULE, EXTENDED",3202725,CDM,250,RC,,,outpatient,,,14.04,10.53,,11.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.65,11.23,
"NF-THEOPHYLLINE 300MG ORAL CAPSULE, EXTE",3202726,CDM,250,RC,,,outpatient,,,1.26,0.95,,1.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.51,1.01,
NF-VITAMIN D2 2000 IU ORAL TABLET,3202727,CDM,250,RC,,,outpatient,,,0.24,0.18,,0.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.19,
NF-EQUALACTIN CHEWABLE TAB,3202728,CDM,250,RC,,,outpatient,,,0.54,0.41,,0.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.22,0.43,
NF-SYSTANE OPHTHALMIC GEL/JELLY 0.3%,3202729,CDM,250,RC,,,outpatient,,,3.77,2.83,,3.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.52,3.02,
NF-RESTASIS OPHTH EMULSION 0.05%,3202730,CDM,250,RC,,,outpatient,,,28.73,21.55,,22.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.56,22.98,
"NYSTATIN TABLET 500,000U",3202731,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-ALEVE 220MG ORAL TABLET,3202732,CDM,250,RC,,,outpatient,,,0.38,0.29,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
NF-VITAMIN C 250 MG ORAL TABLET,3202733,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
NF-EYE DROP ADVANCED RELIEF  OPHTH SOLN,3202734,CDM,250,RC,,,outpatient,,,0.99,0.74,,0.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.79,
NF-BUPROPION HCL 100MG ORAL TABLET,3202735,CDM,250,RC,,,outpatient,,,3.55,2.66,,2.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.43,2.84,
NF-BETHANECHOL CHLORIDE 50MG ORAL TABLET,3202736,CDM,250,RC,,,outpatient,,,15.8,11.85,,12.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.36,12.64,
NF-ZYPREXA 10MG ORAL TABLET,3202738,CDM,250,RC,,,outpatient,,,62.07,46.55,,49.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.98,49.66,
NF-TRAZODONE HYDROCHLORIDE 150MG ORAL TA,3202739,CDM,250,RC,,,outpatient,,,14.43,10.82,,11.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.81,11.54,
"NF-PRILOSEC 20MG ORAL CAPSULE, DELAYED R",3202740,CDM,250,RC,,,outpatient,,,11.33,8.5,,9.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.56,9.06,
CIPRODEX OTIC SUSPENSION 0.3%-0.1%,3202741,CDM,637,RC,,,outpatient,,,315,236.25,,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.76,252,
JANUVIA ORAL TABLET 25MG,3202742,CDM,637,RC,,,outpatient,,,17.6,13.2,,14.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.08,14.08,
OXYCODONE/APAP TAB 10MG-325MG TAB,3202743,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"NF-VITAMIN D3 2000 IU ORAL CAPSULE, LIQU",3202744,CDM,250,RC,,,outpatient,,,0.92,0.69,,0.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.37,0.74,
NF-PRAVASTATIN 40MG ORAL TABLET,3202745,CDM,250,RC,,,outpatient,,,17.74,13.31,,14.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.14,14.19,
NF-TRAMADOL HCL 50MG ORAL TABLET,3202746,CDM,250,RC,,,outpatient,,,5.99,4.49,,4.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.79,
NF-HYDRALAZINE HCL 50MG ORAL TABLET,3202747,CDM,250,RC,,,outpatient,,,2.08,1.56,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.84,1.66,
NF-MILK OF MAGNESIA 1200MG/15ML ORAL SUS,3202748,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
"NF-PROTONIX 40MG ORAL TABLET, ENTERIC CO",3202749,CDM,250,RC,,,outpatient,,,40.58,30.44,,32.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.33,32.46,
NF-CARAFATE 1 GM ORAL TABLET,3202750,CDM,250,RC,,,outpatient,,,11.95,8.96,,9.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.81,9.56,
NF-PROCHLORPERAZINE 10MG ORAL TABLET,3202751,CDM,250,RC,,,outpatient,,,4.66,3.5,,3.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.88,3.73,
"NF-STOOL SOFTENER 240MG ORAL CAPSULE, LI",3202752,CDM,250,RC,,,outpatient,,,0.53,0.4,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-OMEPRAZOLE CAP DR 40MG,3202753,CDM,250,RC,,,outpatient,,,3.05,2.29,,2.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.23,2.44,
NF-TOPAMAX 50MG ORAL TABLET,3202754,CDM,250,RC,,,outpatient,,,20.15,15.11,,16.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.11,16.12,
NF-LISINOPRIL 5MG ORAL TABLET,3202755,CDM,250,RC,,,outpatient,,,5.57,4.18,,4.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.24,4.46,
NF-ULORIC ORAL TABLET 40MG,3202756,CDM,250,RC,,,outpatient,,,38.28,28.71,,30.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.4,30.62,
NF-ZYPREXA 15MG ORAL TABLET,3202757,CDM,250,RC,,,outpatient,,,70.21,52.66,,56.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.25,56.17,
NF-OLANZAPINE 15MG ORAL TABLET,3202758,CDM,250,RC,,,outpatient,,,110.53,82.9,,88.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.48,88.42,
NF-BUPROPION HYDROCHLORIDE SR 200 MG ORA,3202759,CDM,250,RC,,,outpatient,,,13.29,9.97,,10.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.35,10.63,
NF-ZIPRASIDONE HCL 80MG ORAL CAPSULE,3202760,CDM,250,RC,,,outpatient,,,80.52,60.39,,64.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.4,64.42,
NF-NITROGLYCERIN 0.4MG SUBLINGUAL TABLET,3202761,CDM,250,RC,,,outpatient,,,2.39,1.79,,1.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.96,1.91,
NF-OCUVITE ORAL TABLET,3202762,CDM,250,RC,,,outpatient,,,0.36,0.27,,0.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.29,
"NF-NEXIUM 40MG ORAL CAPSULE, DELAYED REL",3202763,CDM,250,RC,,,outpatient,,,28.48,21.36,,22.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.46,22.78,
NF-POTASSIUM CHLORIDE 10MEQ ORAL CAPSULE,3202764,CDM,250,RC,,,outpatient,,,3.67,2.75,,2.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.48,2.94,
NF-LORAZEPAM 2MG ORAL TABLET,3202765,CDM,250,RC,,,outpatient,,,4.65,3.49,,3.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.87,3.72,
NF-D-3 1000 IU ORAL CAPSULE,3202766,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
NF-TOPAMAX 25MG ORAL CAPSULE,3202767,CDM,637,RC,,,outpatient,,,11.54,8.66,,9.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.64,9.23,
NF-PHENOBARBITAL 60MG ORAL TABLET,3202768,CDM,637,RC,,,outpatient,,,0.33,0.25,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-FIORICET 50MG-300MG-40MG ORAL CAPSULE,3202769,CDM,250,RC,,,outpatient,,,16.97,12.73,,13.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.83,13.58,
NF-PROVIGIL ORAL TABLET 100MG,3202770,CDM,250,RC,,,outpatient,,,34.65,25.99,,27.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.94,27.72,
NF-RESTORIL CAP 7.5MG,3202771,CDM,250,RC,,,outpatient,,,30.36,22.77,,24.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.22,24.29,
NF-EXCEDRIN MIGRAINE TAB 250MG-250MG-65M,3202772,CDM,250,RC,,,outpatient,,,0.4,0.3,,0.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.32,
NF-MAXALT TAB 5MG,3202773,CDM,250,RC,,,outpatient,,,153.32,114.99,,122.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.7,122.66,
NF-ULORIC ORAL TABLET 40MG,3202774,CDM,250,RC,,,outpatient,,,38.28,28.71,,30.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.4,30.62,
PR US PANCREAS,4110023,CDM,972,RC,7670526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
PR US SOFT TISSUE HEAD AND NECK,4110028,CDM,972,RC,7653626,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
PR US SPLEEN,4110029,CDM,972,RC,7670526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-NEXIUM CAP DR 40MG,3202778,CDM,250,RC,,,outpatient,,,37.14,27.86,,29.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.95,29.71,
NF-RESTASIS OPHTH EMULSION 0.05%,3202779,CDM,250,RC,,,outpatient,,,28.73,21.55,,22.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.56,22.98,
NF-PRAZOSIN HCL 1MG ORAL CAPSULE,3202780,CDM,250,RC,,,outpatient,,,3.31,2.48,,2.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.33,2.65,
NF-TRAZODONE HYDROCHLORIDE 150MG ORAL TA,3202781,CDM,250,RC,,,outpatient,,,9.3,6.98,,7.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.74,7.44,
NF-NIZORAL 2% TOPICAL APPLICATION SHAMPO,3202782,CDM,250,RC,,,outpatient,,,0.91,0.68,,0.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.37,0.73,
NF-PEPCID 40MG ORAL TABLET,3202783,CDM,250,RC,,,outpatient,,,82.9,62.18,,66.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.36,66.32,
NF-ZINC SULFATE 220 MG ORAL TABLET,3202784,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-LABETALOL HCL 300MG ORAL TABLET,3202785,CDM,250,RC,,,outpatient,,,4.26,3.2,,3.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.41,
NF-VIMPAT 150MG ORAL TABLET,3202786,CDM,250,RC,,,outpatient,,,48.99,36.74,,39.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.71,39.19,
NF-TRANDATE TAB 300MG,3202787,CDM,250,RC,,,outpatient,,,3.85,2.89,,3.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.55,3.08,
NF-ISOSOURCE 1.5 CAL LIQUID,3202788,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
BYSTOLIC ORAL TABLET 20MG,3202789,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-VFEND I.V. INJECTION 200MG,3202790,CDM,250,RC,,,outpatient,,,662.41,496.81,,529.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,266.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,331.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,529.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,266.55,529.93,
VFEND I.V. INJECTION 200MG,3202791,CDM,250,RC,,,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,144.86,288,
"NF-OMEPRAZOLE 40MG ORAL CAPSULE, DELAYED",3202792,CDM,250,RC,,,outpatient,,,27.36,20.52,,21.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.01,21.89,
"NF-OMEPRAZOLE 20MG ORAL CAPSULE, DELAYED",3202793,CDM,250,RC,,,outpatient,,,16.46,12.35,,13.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,13.17,
NF-DIGOXIN 0.125MG ORAL TABLET,3202794,CDM,250,RC,,,outpatient,,,1.05,0.79,,0.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.42,0.84,
NF-AMITRIPTYLINE 10MG ORAL TABLET,3202795,CDM,637,RC,,,outpatient,,,2.77,2.08,,2.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.11,2.22,
NF-GLIPIZIDE ER ORAL TAB ER 2.5MG,3202796,CDM,250,RC,,,outpatient,,,3.49,2.62,,2.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.4,2.79,
ONDANSETRON ORAL SOLUTION 4MG/5ML,3202797,CDM,637,RC,,,outpatient,,,28.75,21.56,,23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.57,23,
"NF-BETA CAROTENE CAPSULE 10,000IU",3202798,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-BRINTELLIX ORAL TABLET 5MG,3202799,CDM,250,RC,,,outpatient,,,42.85,32.14,,34.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.24,34.28,
GLIPIZIDE ORAL TAB ER 2.5MG,3202800,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
"NF-DITROPAN XL 15MG ORAL TABLET, EXTENDE",3202801,CDM,250,RC,,,outpatient,,,15.66,11.75,,12.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.3,12.53,
NF-CALCIUM 600 600MG ORAL TABLET,3202802,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-PERCOCET 7.5MG-325MG ORAL TABLET,3202803,CDM,250,RC,,,outpatient,,,16.79,12.59,,13.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.76,13.43,
NF-DITROPAN XL TAB ER 15MG,3202806,CDM,250,RC,,,outpatient,,,14.77,11.08,,11.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.94,11.82,
NF-PERCOCET TAB 7.5MG-325MG,3202807,CDM,250,RC,,,outpatient,,,41.6,31.2,,33.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.74,33.28,
NF-SYMBYAX CAP 6MG-50MG,3202808,CDM,250,RC,,,outpatient,,,59.54,44.66,,47.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.96,47.63,
NF-CLOPIDOGREL 75MG ORAL TABLET,3202810,CDM,250,RC,,,outpatient,,,18.77,14.08,,15.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.55,15.02,
NF-ALPRAZOLAM 1MG ORAL TABLET,3202811,CDM,250,RC,,,outpatient,,,3.34,2.51,,2.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.34,2.67,
NF-PRILOSEC CAPSULE 40MG,3202812,CDM,250,RC,,,outpatient,,,28.74,21.56,,22.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.56,22.99,
NF-KEPPRA 750MG ORAL TABLET,3202814,CDM,250,RC,,,outpatient,,,14.05,10.54,,11.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.65,11.24,
NF-TOPIRAMATE 50MG ORAL TABLET,3202815,CDM,250,RC,,,outpatient,,,18.86,14.15,,15.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.59,15.09,
NF-KEPPRA ORAL TABLET 750MG,3202816,CDM,250,RC,,,outpatient,,,20.57,15.43,,16.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.28,16.46,
NF-TOPIRAMATE CAP ER 50MG,3202817,CDM,250,RC,,,outpatient,,,33.26,24.95,,26.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.38,26.61,
NF-IMITREX 50MG ORAL TABLET,3202818,CDM,250,RC,,,outpatient,,,213.92,160.44,,171.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.08,171.14,
NF-ZINC 50 MG ORAL TABLET,3202819,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-FERROUS GLUCONATE 325MG ORAL TABLET,3202820,CDM,250,RC,,,outpatient,,,0.33,0.25,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-NATURE\'S BLEND MULTI-VITAMIN ORAL TA,3202821,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-ZANAFLEX CAPSULE 4MG ORAL CAPSULE,3202822,CDM,250,RC,,,outpatient,,,14.13,10.6,,11.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.69,11.3,
NF-XARELTO 20MG ORAL TABLET,3202823,CDM,250,RC,,,outpatient,,,49.32,36.99,,39.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.85,39.46,
NF-FOLIC ACID 800 MCG ORAL TABLET,3202824,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-NAPROXEN 220MG ORAL TABLET,3202825,CDM,250,RC,,,outpatient,,,0.47,0.35,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-EXCEDRIN MIGRAINE 250MG-250MG-65MG OR,3202826,CDM,250,RC,,,outpatient,,,0.49,0.37,,0.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.39,
NF-ABANEU-SL 600MCG-600MCG SUBLINGUAL TA,3202827,CDM,250,RC,,,outpatient,,,0.79,0.59,,0.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.32,0.63,
NF-CALCIUM CITRATE 250 MG ORAL TABLET,3202828,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-CEREFOLIN 1MG-5.635MG-50MG-5MG ORAL T,3202829,CDM,250,RC,,,outpatient,,,18.28,13.71,,14.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.36,14.62,
NF-HYDROCHLOROTHIAZIDE 12.5MG ORAL CAPSU,3202830,CDM,250,RC,,,outpatient,,,1.57,1.18,,1.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.63,1.26,
"NF-ZOFRAN 4MG ORAL TABLET, DISINTEGRATIN",3202831,CDM,250,RC,,,outpatient,,,106.54,79.91,,85.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.87,85.23,
NF-GABAPENTIN 600MG ORAL TABLET,3202832,CDM,250,RC,,,outpatient,,,9.35,7.01,,7.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,7.48,
NF-OXYCODONE HCL 10MG ORAL TABLET,3202833,CDM,250,RC,,,outpatient,,,2.31,1.73,,1.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.85,
NORGESTIM/ETHINYL ESTRADIOL 0.25MG-35MCG,3202835,CDM,637,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-MOTION SICKNESS RELIEF CHEW TAB 25MG,3202836,CDM,250,RC,,,outpatient,,,1.09,0.82,,0.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.44,0.87,
NF-A/B OTIC OTIC SOLUTION,3202837,CDM,250,RC,,,outpatient,,,1.74,1.31,,1.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.39,
NF-ZYRTEC CHEW TAB 5MG,3202838,CDM,250,RC,,,outpatient,,,12.08,9.06,,9.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.86,9.66,
NF-FLOXIN OTIC SOLUTION 0.3%,3202839,CDM,250,RC,,,outpatient,,,78.59,58.94,,62.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.62,62.87,
NF-PROMETHAZINE HCL ORAL TABLET 12.5MG,3202840,CDM,250,RC,,,outpatient,,,2.53,1.9,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.02,
NF-CETIRIZINE HCL ORAL SYRUP 1MG/1ML,3202841,CDM,250,RC,,,outpatient,,,1.12,0.84,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
NF-CETIRIZINE HCL ORAL SOLUTION 1MG/1ML,3202842,CDM,250,RC,,,outpatient,,,1.13,0.85,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
NF-MEXILETINE HCL CAP 200MG,3202843,CDM,250,RC,,,outpatient,,,3.96,2.97,,3.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.59,3.17,
NF-SUCRALFATE ORAL TABLET 1GM,3202844,CDM,250,RC,,,outpatient,,,2.94,2.21,,2.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,2.35,
NF-GABAPENTIN 800MG ORAL TABLET,3202845,CDM,250,RC,,,outpatient,,,15.78,11.84,,12.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.35,12.62,
NF-CLONAZEPAM 1MG ORAL TABLET,3202846,CDM,250,RC,,,outpatient,,,3.17,2.38,,2.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.28,2.54,
"NF-RISPERIDONE 2 MG ORAL TABLET, DISINTE",3202847,CDM,637,RC,,,outpatient,,,34.52,25.89,,27.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.89,27.62,
NF-BENZTROPINE MESYLATE 2MG ORAL TABLET,3202848,CDM,250,RC,,,outpatient,,,1.82,1.37,,1.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.46,
"NF-ASPIRIN 81MG ORAL TABLET, CHEWABLE",3202849,CDM,637,RC,,,outpatient,,,0.35,0.26,,0.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.28,
NF-HALDOL DECANOATE 100MG/1ML INTRAMUSCU,3202850,CDM,250,RC,,,outpatient,,,670.62,502.97,,536.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,335.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,335.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,335.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,335.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,536.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,536.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,536.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,536.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,269.86,536.5,
NF-SEROQUEL 100MG ORAL TABLET,3202851,CDM,250,RC,,,outpatient,,,29.18,21.89,,23.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.74,23.34,
"NF-OMEPRAZOLE 40MG ORAL CAPSULE, DELAYED",3202852,CDM,250,RC,,,outpatient,,,29.48,22.11,,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.86,23.58,
NF-METOCLOPRAMIDE 10MG ORAL TABLET,3202853,CDM,250,RC,,,outpatient,,,3.76,2.82,,3.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3.01,
"NF-MECLIZINE 25MG ORAL TABLET, CHEWABLE",3202854,CDM,250,RC,,,outpatient,,,10.63,7.97,,8.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.28,8.5,
NF-OXCARBAZEPINE 600MG ORAL TABLET,3202855,CDM,250,RC,,,outpatient,,,18.21,13.66,,14.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.33,14.57,
"NF-OMEGA-3 ORAL CAPSULE, LIQUID FILLED",3202856,CDM,250,RC,,,outpatient,,,0.77,0.58,,0.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.31,0.62,
NF-TRIMETHOPRIM 100MG ORAL TABLET,3202857,CDM,250,RC,,,outpatient,,,2.53,1.9,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.02,
NF-BIOTIN ORAL TABLET 5MG,3202858,CDM,250,RC,,,outpatient,,,0.45,0.34,,0.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.18,0.36,
NF-MEXILETINE HCL CAP 200MG,3202859,CDM,250,RC,,,outpatient,,,3.96,2.97,,3.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.59,3.17,
NF-SUCRALFATE ORAL TABLET 1GM,3202860,CDM,250,RC,,,outpatient,,,2.78,2.09,,2.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,2.22,
NF-KLOR-CON ORAL POWDER FOR SOLUTION 20M,3202861,CDM,250,RC,,,outpatient,,,25.13,18.85,,20.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.11,20.1,
"NF-DEPAKOTE 125MG ORAL TABLET, DELAYED R",3202862,CDM,250,RC,,,outpatient,,,6.58,4.94,,5.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.65,5.26,
NF-PIMOZIDE 1MG ORAL TABLET,3202863,CDM,250,RC,,,outpatient,,,6.77,5.08,,5.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.72,5.42,
"NF-NEXIUM 40MG ORAL CAPSULE, DELAYED REL",3202864,CDM,250,RC,,,outpatient,,,36.72,27.54,,29.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.78,29.38,
NF-A.M.-75 MULTIVIT/MULTIMINERAL ORAL TA,3202865,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
"NF-ASPIRIN 81MG ORAL TABLET, ENTERIC COA",3202866,CDM,250,RC,,,outpatient,,,0.93,0.7,,0.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.37,0.74,
NF-METOPROLOL SUCCINATE 50MG ORAL TABLET,3202867,CDM,250,RC,,,outpatient,,,10.61,7.96,,8.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.27,8.49,
NF-VITAMIN B6 100MG ORAL TABLET,3202868,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NORETHINDRONE ORAL TABLET 0.35MG,3202869,CDM,637,RC,,,outpatient,,,44.29,33.22,,35.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.82,35.43,
NF-FERROUS GLUCONATE ORAL TABLET 324MG,3202870,CDM,250,RC,,,outpatient,,,0.8,0.6,,0.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.32,0.64,
NF-CRESTOR 40MG ORAL TABLET,3202871,CDM,250,RC,,,outpatient,,,31.98,23.99,,25.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.87,25.58,
NF-MYRBETRIQ TAB ER 25MG,3202872,CDM,250,RC,,,outpatient,,,40.29,30.22,,32.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.21,32.23,
METHIMAZOLE TABLET 5MG,3202873,CDM,637,RC,,,outpatient,,,1.64,1.23,,1.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.66,1.31,
NF-VERAPAMIL HCL 120MG ORAL TABLET,3202874,CDM,250,RC,,,outpatient,,,2.53,1.9,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.02,
NF-LOESTRIN 24 FE 20MCG-1MG ORAL TABLET,3202875,CDM,250,RC,,,outpatient,,,13.16,9.87,,10.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.3,10.53,
NF-WELLBUTRIN 100MG ORAL TABLET,3202876,CDM,250,RC,,,outpatient,,,14.44,10.83,,11.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.81,11.55,
NF-ADVAIR DISKUS 250/50 0.25MG-0.05MG/1I,3202877,CDM,250,RC,,,outpatient,,,17.63,13.22,,14.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,14.1,
NF-JANUVIA 50MG ORAL TABLET,3202878,CDM,250,RC,,,outpatient,,,53.78,40.34,,43.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.64,43.02,
NF-ISOSORBIDE DINITRATE 30MG ORAL TABLET,3202879,CDM,250,RC,,,outpatient,,,4.85,3.64,,3.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.95,3.88,
NF-CYANOCOBALAMIN 1000MCG/1ML INJECTION,3202880,CDM,250,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
NF-EPIPEN 0.3MG/0.3ML\;NO STREN MULTIPLE,3202881,CDM,250,RC,,,outpatient,,,307.77,230.83,,246.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.85,246.22,
NF-LEVSIN/SL 0.125MG SUBLINGUAL TABLET,3202882,CDM,250,RC,,,outpatient,,,3.57,2.68,,2.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.44,2.86,
"NF-MUCINEX 600MG ORAL TABLET, EXTENDED R",3202883,CDM,250,RC,,,outpatient,,,3.18,2.39,,2.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.28,2.54,
NF-PREDNISONE 10MG ORAL TABLET,3202884,CDM,250,RC,,,outpatient,,,1.23,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
NF-LASIX 40MG ORAL TABLET,3202885,CDM,250,RC,,,outpatient,,,2.07,1.55,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.83,1.66,
"NF-PROTONIX 40MG ORAL TABLET, ENTERIC CO",3202886,CDM,250,RC,,,outpatient,,,59.44,44.58,,47.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.92,47.55,
NF-KEPPRA 500MG ORAL TABLET,3202887,CDM,250,RC,,,outpatient,,,32.41,24.31,,25.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.04,25.93,
NF-ARTIFICIAL TEARS 0.2%-0.2%-1% OPHTHAL,3202888,CDM,250,RC,,,outpatient,,,0.34,0.26,,0.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.27,
NF-COUMADIN 6MG ORAL TABLET,3202889,CDM,250,RC,,,outpatient,,,4.2,3.15,,3.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.69,3.36,
"NF-ASPIRIN 325MG ORAL TABLET, ENTERIC CO",3202890,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-TERAZOSIN HCL 5MG ORAL CAPSULE,3202891,CDM,250,RC,,,outpatient,,,11.88,8.91,,9.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.78,9.5,
"NF-OMEPRAZOLE 20MG ORAL CAPSULE, DELAYED",3202892,CDM,250,RC,,,outpatient,,,15.36,11.52,,12.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.18,12.29,
NF-SERTRALINE 50MG ORAL TABLET,3202893,CDM,250,RC,,,outpatient,,,21.08,15.81,,16.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.48,16.86,
NF-AMLODIPINE BESYLATE 5MG ORAL TABLET,3202894,CDM,250,RC,,,outpatient,,,6.4,4.8,,5.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.58,5.12,
NF-NORTRIPTYLINE HCL CAP 50MG,3202895,CDM,250,RC,,,outpatient,,,6.74,5.06,,5.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.71,5.39,
NF-SILENOR 3MG ORAL TABLET,3202896,CDM,250,RC,,,outpatient,,,49.51,37.13,,39.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.92,39.61,
NF-PRAVASTATIN 20MG ORAL TABLET,3202897,CDM,250,RC,,,outpatient,,,12.09,9.07,,9.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.87,9.67,
NF-ADVAIR DISKUS 250/50 0.25MG-0.05MG/1I,3202898,CDM,250,RC,,,outpatient,,,22.93,17.2,,18.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.23,18.34,
NF-TRIUMEQ 600MG-50MG-300MG ORAL TABLET,3202899,CDM,250,RC,,,outpatient,,,339.56,254.67,,271.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,136.64,271.65,
NF-XIFAXAN 550MG ORAL TABLET,3202900,CDM,250,RC,,,outpatient,,,124.41,93.31,,99.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.06,99.53,
NF-MELATONIN 5 MG ORAL TABLET,3202901,CDM,250,RC,,,outpatient,,,0.32,0.24,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-KLONOPIN 1MG ORAL TABLET,3202902,CDM,250,RC,,,outpatient,,,10.95,8.21,,8.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.41,8.76,
NF-REMERON 30MG ORAL TABLET,3202903,CDM,250,RC,,,outpatient,,,16.85,12.64,,13.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.78,13.48,
NF-AMARYL 1MG ORAL TABLET,3202904,CDM,250,RC,,,outpatient,,,1.98,1.49,,1.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.58,
NF-LACTULOSE 10GM/15ML ORAL SYRUP,3202905,CDM,250,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
"NF-FISH OIL 1000MG ORAL CAPSULE, LIQUID",3202906,CDM,250,RC,,,outpatient,,,0.88,0.66,,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.35,0.7,
"NF-OMEPRAZOLE 20MG ORAL CAPSULE, DELAYED",3202907,CDM,250,RC,,,outpatient,,,36.13,27.1,,28.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.54,28.9,
NF-DEXTROAMPHETAMINE SULFATE SOLN 5MG/5M,3202908,CDM,250,RC,,,outpatient,,,7.51,5.63,,6.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6.01,
NF-GUANFACINE HCL ORAL TABLET ER 1MG,3202909,CDM,250,RC,,,outpatient,,,17.47,13.1,,13.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.03,13.98,
NF-GUANFACINE HCL ORAL TAB ER 1MG,3202910,CDM,250,RC,,,outpatient,,,38.82,29.12,,31.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.62,31.06,
NF-ZOLOFT ORAL TABLET 25MG,3202912,CDM,250,RC,,,outpatient,,,14.52,10.89,,11.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.84,11.62,
NF-PRADAXA CAP 75MG,3202913,CDM,250,RC,,,outpatient,,,24.68,18.51,,19.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.93,19.74,
NF-CLARITIN-D 24 HOUR 24 HR TAB ER 10MG-,3202914,CDM,250,RC,,,outpatient,,,4.37,3.28,,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.76,3.5,
NF-NEURONTIN ORAL TABLET 800MG,3202915,CDM,250,RC,,,outpatient,,,16.65,12.49,,13.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.7,13.32,
NF-METOPROLOL SUCCINATE 50MG ORAL TABLET,3202916,CDM,250,RC,,,outpatient,,,3.34,2.51,,2.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.34,2.67,
NF-IRON 325MG ORAL TABLET,3202917,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
"NF-VITAMIN D 2000 IU ORAL CAPSULE, LIQUI",3202918,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
"NF-NEXIUM 20MG ORAL CAPSULE, DELAYED REL",3202919,CDM,637,RC,,,outpatient,,,37.14,27.86,,29.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.95,29.71,
NF-HYDROCORTISONE 10MG ORAL TABLET,3202920,CDM,250,RC,,,outpatient,,,3.69,2.77,,2.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.48,2.95,
NF-KETOTIFEN FUMARATE 0.025% OPHTHALMIC,3202921,CDM,250,RC,,,outpatient,,,47.2,35.4,,37.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.99,37.76,
CITALOPRAM HYDROBROMIDE TABLET 40MG,3202923,CDM,637,RC,,,outpatient,,,2.92,2.19,,2.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,2.34,
NF-AZOR ORAL TABLET 5MG-20MG,3202924,CDM,250,RC,,,outpatient,,,10.88,8.16,,8.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.38,8.7,
NF-COMBIVENT INH AER PWD 103MCG-18MCG/1,3202925,CDM,250,RC,,,outpatient,,,84.93,63.7,,67.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.18,67.94,
NF-DULERA INH AER PWD 5MCG-200MCG/ACT,3202926,CDM,250,RC,,,outpatient,,,93.73,70.3,,74.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.72,74.98,
NF-FENTANYL 100MCG/1HR TRANSDERMAL PATCH,3202927,CDM,250,RC,,,outpatient,,,197.43,148.07,,157.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.45,157.94,
NF-DILTIAZEM HCL 120MG ORAL TABLET,3202928,CDM,250,RC,,,outpatient,,,10.67,8,,8.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.29,8.54,
NF-RANITIDINE 150MG ORAL TABLET,3202929,CDM,250,RC,,,outpatient,,,12.24,9.18,,9.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.93,9.79,
"NF-VITAMIN D3 400IU ORAL TABLET, CHEWABL",3202930,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-POTASSIUM CHLORIDE 10MEQ ORAL CAPSULE,3202931,CDM,250,RC,,,outpatient,,,3.67,2.75,,2.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.48,2.94,
NF-LACTULOSE 10GM/15ML ORAL SOLUTION,3202932,CDM,250,RC,,,outpatient,,,0.26,0.2,,0.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.21,
NF-RIBOFLAVIN POWDER,3202933,CDM,250,RC,,,outpatient,,,1.09,0.82,,0.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.44,0.87,
NF-DIOVAN 320MG ORAL TABLET,3202934,CDM,250,RC,,,outpatient,,,34.24,25.68,,27.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.78,27.39,
NF-SODIUM CHLORIDE 7% INHALATION SOLUTIO,3202935,CDM,250,RC,,,outpatient,,,0.7,0.53,,0.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.28,0.56,
NF-OLIVE LEAF EXTRACT 500 MG ORAL CAPSUL,3202936,CDM,250,RC,,,outpatient,,,0.52,0.39,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-MAGNESIUM 200 MG ORAL TABLET,3202937,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
"NF-COENZYME Q10 200 MG ORAL TABLET, CHEW",3202938,CDM,250,RC,,,outpatient,,,6.22,4.67,,4.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.5,4.98,
"NF-NIFEDIPINE 30MG ORAL TABLET, EXTENDED",3202940,CDM,637,RC,,,outpatient,,,4.8,3.6,,3.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.93,3.84,
NF-IPRATROPIUM BROMIDE-ALBUTEROL SULFATE,3202941,CDM,637,RC,,,outpatient,,,2.7,2.03,,2.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.16,
NF-HYDROCHLOROTHIAZIDE 25MG ORAL TABLET,3202942,CDM,250,RC,,,outpatient,,,1.23,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
NF-MILK OF MAGNESIA 1200MG/15ML ORAL SUS,3202943,CDM,637,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-VISION VITAMINS WITH LUTEIN ORAL TABL,3202944,CDM,250,RC,,,outpatient,,,0.5,0.38,,0.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.4,
NF-XANAX 1MG ORAL TABLET,3202945,CDM,250,RC,,,outpatient,,,20.11,15.08,,16.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.09,16.09,
NF-BROVANA 15MCG/2ML INHALATION SOLUTION,3202948,CDM,250,RC,,,outpatient,,,27.97,20.98,,22.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.26,22.38,
"NF-GOOD NEIGHBOR HAIR, SKIN & NAILS TABL",3202949,CDM,250,RC,,,outpatient,,,0.5,0.38,,0.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.4,
NF-CALCIUM 600 600MG ORAL TABLET,3202950,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-VITAMIN C 500MG ORAL TABLET,3202952,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-SIMVASTATIN 80MG ORAL TABLET,3202953,CDM,250,RC,,,outpatient,,,18.21,13.66,,14.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.33,14.57,
"NF-OMEPRAZOLE 40MG ORAL CAPSULE, DELAYED",3202954,CDM,250,RC,,,outpatient,,,27.04,20.28,,21.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.88,21.63,
NF-LISINOPRIL 5MG ORAL TABLET,3202955,CDM,250,RC,,,outpatient,,,3.56,2.67,,2.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.43,2.85,
NF-LEVALBUTEROL 1.25MG/3ML INHALATION SO,3202956,CDM,250,RC,,,outpatient,,,8.27,6.2,,6.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.33,6.62,
"NF-SINGULAIR 5MG ORAL TABLET, CHEWABLE",3202957,CDM,250,RC,,,outpatient,,,23.26,17.45,,18.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.36,18.61,
NF-POTASSIUM CHLORIDE 20MEQ/15ML ORAL SO,3202958,CDM,250,RC,,,outpatient,,,0.41,0.31,,0.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.33,
"NF-ASPIR-TRIN 325MG ORAL TABLET, ENTERIC",3202959,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
NF-LISINOPRIL 5MG ORAL TABLET,3202961,CDM,250,RC,,,outpatient,,,3.56,2.67,,2.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.43,2.85,
NF-VIVELLE-DOT 0.075MG/24HR TRANSDERMAL,3202962,CDM,250,RC,,,outpatient,,,61.35,46.01,,49.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.69,49.08,
NF-PILOCARPINE HCL ORAL TABLET 5MG,3202963,CDM,250,RC,,,outpatient,,,5.63,4.22,,4.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.5,
NF-TOPAMAX 100MG ORAL TABLET,3202964,CDM,637,RC,,,outpatient,,,57.4,43.05,,45.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.1,45.92,
NF-NP THYROID 60MG ORAL TABLET,3202965,CDM,250,RC,,,outpatient,,,0.54,0.41,,0.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.22,0.43,
NF-METOPIRONE CAP 250MG,3202966,CDM,250,RC,,,outpatient,,,44.4,33.3,,35.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.87,35.52,
NF-OXCARBAZEPINE ORAL TABLET 150MG,3202967,CDM,250,RC,,,outpatient,,,5.35,4.01,,4.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.15,4.28,
NF-ALEVE TABLET 220MG,3202968,CDM,250,RC,,,outpatient,,,0.47,0.35,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
FLUOCINONIDE GEL/JELLY 0.05%,3202969,CDM,637,RC,,,outpatient,,,38.25,28.69,,30.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.39,30.6,
PR US CAROTID DOPPLER UNI/LIMITED LT,4110041,CDM,972,RC,9388226LT,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
CLINDAMYCIN PHOSPHATE GEL/JELLY 1%,3202971,CDM,250,RC,,,outpatient,,,67.09,50.32,,53.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27,53.67,
NF-JUVEN ORAL POWDER FOR SOLUTION,3202974,CDM,250,RC,,,outpatient,,,0.35,0.26,,0.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.28,
"NF-MUCINEX D 600MG-60MG ORAL TABLET, EXT",3202975,CDM,637,RC,,,outpatient,,,2.27,1.7,,1.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.82,
NF-CARDIZEM CD 24 HR CAP ER 300MG,3202976,CDM,250,RC,,,outpatient,,,247.42,185.57,,197.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.56,197.94,
NF-CARDIZEM CD 24 HR CAP ER 300MG,3202977,CDM,250,RC,,,outpatient,,,244.52,183.39,,195.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.39,195.62,
NF-URECHOLINE ORAL TABLET 10MG,3202978,CDM,250,RC,,,outpatient,,,14.78,11.09,,11.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.95,11.82,
NF-MUCINEX D ORAL TAB ER 60MG-600MG,3202979,CDM,250,RC,,,outpatient,,,3.42,2.57,,2.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.38,2.74,
NF-GABAPENTIN 600MG ORAL TABLET,3202980,CDM,250,RC,,,outpatient,,,9.35,7.01,,7.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.76,7.48,
NF-PROTEINEX ORAL LIQUID,3202981,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-ASPIRIN LOW DOSE 81MG ORAL TABLET,3202982,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-SUPER B COMPLEX W/B-12 ORAL TABLET,3202983,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
"NF-VITAMIN D3 2000 IU ORAL CAPSULE, LIQU",3202984,CDM,250,RC,,,outpatient,,,0.49,0.37,,0.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.39,
NF-OMEPRAZOLE CAP DR 40MG,3202985,CDM,250,RC,,,outpatient,,,34.53,25.9,,27.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.89,27.62,
NF-LISINOPRIL/HYDROCHLOROTHIAZIDE 20MG-1,3202986,CDM,250,RC,,,outpatient,,,8.85,6.64,,7.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.56,7.08,
NF-HYDROCODONE BITARTRATE-ACETAMINOPHEN,3202987,CDM,250,RC,,,outpatient,,,10.23,7.67,,8.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.12,8.18,
NF-ADVAIR DISKUS 250/50 0.25MG-0.05MG/1I,3202988,CDM,250,RC,,,outpatient,,,23.1,17.33,,18.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.3,18.48,
NF-TUSSIONEX PENNKINETIC 8MG/5ML-10MG/5M,3202989,CDM,250,RC,,,outpatient,,,6.08,4.56,,4.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.45,4.86,
NF-TUDORZA PRESSAIR 400MCG/1 ACTUATION I,3202990,CDM,250,RC,,,outpatient,,,1249.42,937.07,,999.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,687.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,937.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,502.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,502.77,999.54,
NF-OMEPRAZOLE CAP DR 10MG,3202991,CDM,250,RC,,,outpatient,,,12.83,9.62,,10.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,10.26,
NF-BETAXOLOL 20MG ORAL TABLET,3202992,CDM,250,RC,,,outpatient,,,6.89,5.17,,5.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,5.51,
NF-ARICEPT 10MG ORAL TABLET,3202993,CDM,250,RC,,,outpatient,,,74.9,56.18,,59.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.14,59.92,
"NF-TEGRETOL 100MG ORAL TABLET, CHEWABLE",3202994,CDM,250,RC,,,outpatient,,,2.85,2.14,,2.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.15,2.28,
NF-LAMICTAL 200MG ORAL TABLET,3202995,CDM,250,RC,,,outpatient,,,7.15,5.36,,5.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.88,5.72,
NF-TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5M,3202997,CDM,250,RC,,,outpatient,,,1.48,1.11,,1.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.18,
"NF-MECLIZINE 25MG ORAL TABLET, CHEWABLE",3202998,CDM,250,RC,,,outpatient,,,8.34,6.26,,6.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.36,6.67,
"NF-TOPROL XL 50MG ORAL TABLET, EXTENDED",3202999,CDM,250,RC,,,outpatient,,,5.31,3.98,,4.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.14,4.25,
NF-OXYCODONE HCL 5MG ORAL CAPSULE,3203000,CDM,250,RC,,,outpatient,,,6.84,5.13,,5.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.75,5.47,
NF-ISOSORBIDE MONONITRATE 120MG ORAL TAB,3203001,CDM,250,RC,,,outpatient,,,2.81,2.11,,2.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.13,2.25,
NF-SAVELLA ORAL TABLET 50MG,3203002,CDM,250,RC,,,outpatient,,,27.96,20.97,,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.25,22.37,
NF-EDARBI ORAL TABLET 80MG,3203003,CDM,250,RC,,,outpatient,,,20.07,15.05,,16.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.08,16.06,
NF-SAVELLA ORAL TABLET 50MG,3203004,CDM,250,RC,,,outpatient,,,8.65,6.49,,6.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.48,6.92,
NF-REGLAN 5MG/1ML INTRAVENOUS SOLUTION,3203005,CDM,250,RC,,,outpatient,,,0.78,0.59,,0.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.31,0.62,
"NF-INVEGA 6MG ORAL TABLET, EXTENDED RELE",3203006,CDM,250,RC,,,outpatient,,,138.24,103.68,,110.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55.63,110.59,
NF-LETROZOLE 2.5MG ORAL TABLET,3203007,CDM,250,RC,,,outpatient,,,67.02,50.27,,53.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.97,53.62,
NF-LISINOPRIL 10MG ORAL TABLET,3203008,CDM,250,RC,,,outpatient,,,0.51,0.38,,0.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.41,
NF-ZOFRAN 4MG ORAL TABLET,3203009,CDM,250,RC,,,outpatient,,,98.32,73.74,,78.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.56,78.66,
NF-VENTOLIN HFA 0.09MG/1INH INHALATION A,3203010,CDM,250,RC,,,outpatient,,,11.03,8.27,,8.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.44,8.82,
NF-CYANOCOBALAMIN 1000MCG/1ML INJECTION,3203011,CDM,250,RC,,,outpatient,,,1.06,0.8,,0.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.43,0.85,
NF-NASONEX 0.05MG/ACTUATION NASAL SPRAY,3203012,CDM,250,RC,,,outpatient,,,38.77,29.08,,31.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.6,31.02,
NF-MILK OF MAGNESIA 400 MG/5 ML ORAL SUS,3203013,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-EFFEXOR 75MG ORAL TABLET,3203014,CDM,250,RC,,,outpatient,,,13.24,9.93,,10.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.33,10.59,
NF-PLAVIX 75MG ORAL TABLET,3203015,CDM,250,RC,,,outpatient,,,28.62,21.47,,22.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.52,22.9,
NF-TYLENOL EXTRA STRENGTH 500MG ORAL CAP,3203016,CDM,250,RC,,,outpatient,,,0.5,0.38,,0.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.4,
NF-PEPTO-BISMOL 262MG/15ML ORAL SUSPENSI,3203017,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-BYETTA 250MCG/1ML SUBCUTANEOUS SOLUTI,3203018,CDM,250,RC,,,outpatient,,,1580.24,1185.18,,1264.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,635.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,790.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,790.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,790.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,790.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,869.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,635.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,635.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1264.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1185.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1264.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,635.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1264.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,635.89,1264.19,
NF-HYDROCODONE AND APAP 7.5MG-325MG/15ML,3203019,CDM,250,RC,,,outpatient,,,0.8,0.6,,0.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.32,0.64,
NF-ALPRAZOLAM       TAB  1MG,3203020,CDM,250,RC,,,outpatient,,,4.2,3.15,,3.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.69,3.36,
NF-SOTALOL HCL 120MG ORAL TABLET,3203021,CDM,250,RC,,,outpatient,,,12.65,9.49,,10.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.09,10.12,
NF-ASCORBIC ACID 250 MG ORAL TABLET,3203022,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
NF-PREDNISOLONE SODIUM PHOSPHATE 1% OPHT,3203023,CDM,250,RC,,,outpatient,,,21.29,15.97,,17.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.57,17.03,
"NF-OMEPRAZOLE 20MG ORAL CAPSULE, DELAYED",3203024,CDM,250,RC,,,outpatient,,,12.48,9.36,,9.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.02,9.98,
"NF-ALKA-MINTS 850 MG ORAL TABLET, CHEWAB",3203025,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-OMEPRAZOLE CAP DR 20MG,3203026,CDM,250,RC,,,outpatient,,,19.67,14.75,,15.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.92,15.74,
NF-FERROUS FUMARATE 325 MG ORAL TABLET,3203027,CDM,250,RC,,,outpatient,,,1.82,1.37,,1.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.46,
NF-ENBREL 25MG SUBCUTANEOUS POWDER FOR S,3203028,CDM,250,RC,,,outpatient,,,2069.39,1552.04,,1655.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1138.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,832.72,1655.51,
NF-LISINOPRIL 20MG ORAL TABLET,3203029,CDM,250,RC,,,outpatient,,,4.12,3.09,,3.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.66,3.3,
NF-AMLODIPINE BESYLATE 5MG ORAL TABLET,3203030,CDM,250,RC,,,outpatient,,,6.4,4.8,,5.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.58,5.12,
NF-ADVAIR DISKUS 250/50 0.25MG-0.05MG/1I,3203031,CDM,250,RC,,,outpatient,,,28.75,21.56,,23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.57,23,
NF-TELMISARTAN 40MG ORAL TABLET,3203032,CDM,250,RC,,,outpatient,,,20.43,15.32,,16.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.22,16.34,
NF-NITROGLYCERIN 0.4MG SUBLINGUAL TABLET,3203033,CDM,250,RC,,,outpatient,,,2.39,1.79,,1.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.96,1.91,
NF-JANUMET 500MG-50MG ORAL TABLET,3203034,CDM,250,RC,,,outpatient,,,26.89,20.17,,21.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.82,21.51,
NF-DIAZEPAM 5MG ORAL TABLET,3203035,CDM,250,RC,,,outpatient,,,3.26,2.45,,2.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.31,2.61,
NF-MEXILETINE 150MG ORAL CAPSULE,3203036,CDM,250,RC,,,outpatient,,,4.44,3.33,,3.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,3.55,
NF-PRORENAL VITAL ORAL TABLET,3203037,CDM,250,RC,,,outpatient,,,1.3,0.98,,1.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.52,1.04,
NF-ALBUTEROL INHALER 0.09MG/ACTUATION IN,3203038,CDM,250,RC,,,outpatient,,,9.32,6.99,,7.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.75,7.46,
NF-ANAPROX DS 550MG ORAL TABLET,3203039,CDM,250,RC,,,outpatient,,,5.81,4.36,,4.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.34,4.65,
NF-OXYBUTYNIN CHLORIDE ORAL TAB ER 10MG,3203043,CDM,250,RC,,,outpatient,,,12.16,9.12,,9.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.89,9.73,
NF-VITAMIN D 5000 IU ORAL TABLET,3203044,CDM,250,RC,,,outpatient,,,6.8,5.1,,5.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.74,5.44,
NF-MECLIZINE HCL 25 MG ORAL TABLET,3203045,CDM,250,RC,,,outpatient,,,1.48,1.11,,1.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.18,
NF-DURAGESIC TD PATCH ER 100MCG/1HR,3203046,CDM,250,RC,,,outpatient,,,279.42,209.57,,223.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,112.44,223.54,
NF-MYRBETRIQ ORAL TABLET 50MG,3203047,CDM,250,RC,,,outpatient,,,43.92,32.94,,35.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.67,35.14,
NF-VITAMIN C 100 MG ORAL TABLET,3203048,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-MULTIPLE VITAMINS W/IRON ORAL TABLET,3203049,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-DIFLUCAN 200MG ORAL TABLET,3203050,CDM,250,RC,,,outpatient,,,186.5,139.88,,149.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.05,149.2,
"NF-POTASSIUM CHLORIDE 20MEQ ORAL TABLET,",3203051,CDM,250,RC,,,outpatient,,,2.32,1.74,,1.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.86,
NF-ONGLYZA ORAL TABLET 2.5MG,3203052,CDM,250,RC,,,outpatient,,,53.77,40.33,,43.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.64,43.02,
"NF-OMEPRAZOLE 20MG ORAL CAPSULE, DELAYED",3203053,CDM,250,RC,,,outpatient,,,32.92,24.69,,26.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.25,26.34,
"NF-COLACE 100MG ORAL CAPSULE, LIQUID FIL",3203054,CDM,637,RC,,,outpatient,,,1.11,0.83,,0.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.89,
NF-LORAZEPAM INTENSOL SOLN 2MG/1ML,3203055,CDM,250,RC,,,outpatient,,,5.92,4.44,,4.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.38,4.74,
NF-SUCRETS REGULAR STRENGTH 2 MG OROMUCO,3203056,CDM,250,RC,,,outpatient,,,0.52,0.39,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NEOMYCIN/POLYMYXIN B/ DEXAMETH OPTH SUSP,3203057,CDM,637,RC,,,outpatient,,,23.82,17.87,,19.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.59,19.06,
NF-VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-1,3203058,CDM,250,RC,,,outpatient,,,20.03,15.02,,16.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.06,16.02,
NF-NAMENDA XR CAP ER 14MG,3203059,CDM,250,RC,,,outpatient,,,52.39,39.29,,41.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.08,41.91,
NF-NAPROXEN ORAL TABLET 220MG,3203060,CDM,250,RC,,,outpatient,,,3.53,2.65,,2.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.42,2.82,
NF-PRILOSEC CAP DR 20MG,3203061,CDM,250,RC,,,outpatient,,,23.51,17.63,,18.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,18.81,
NF-ESTROVEN WEIGHT MANAGEMENT ORAL CAPSU,3203062,CDM,250,RC,,,outpatient,,,0.98,0.74,,0.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.39,0.78,
NF-OMEPRAZOLE CAP DR 40MG,3203063,CDM,250,RC,,,outpatient,,,1.18,0.89,,0.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.47,0.94,
NF-CARDURA TAB 8MG,3203064,CDM,250,RC,,,outpatient,,,7.38,5.54,,5.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.97,5.9,
NF-CALCIUM 600MG ORAL TABLET,3203065,CDM,250,RC,,,outpatient,,,0.26,0.2,,0.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.21,
NF-FIBER HEALTH ORAL TABLET,3203066,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-MAGNESIUM OXIDE 400MG ORAL TABLET,3203067,CDM,250,RC,,,outpatient,,,0.52,0.39,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-ADDERALL 10MG ORAL TABLET,3203068,CDM,250,RC,,,outpatient,,,12.21,9.16,,9.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.91,9.77,
NF-ONGLYZA TAB 5MG,3203070,CDM,250,RC,,,outpatient,,,53.77,40.33,,43.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.64,43.02,
NF-METHOTREXATE ORAL TABLET 2.5MG,3203072,CDM,250,RC,,,outpatient,,,14.99,11.24,,11.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.03,11.99,
NF-GUANFACINE HCL 2MG ORAL TABLET,3203073,CDM,250,RC,,,outpatient,,,4.35,3.26,,3.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.75,3.48,
NF-XANAX 1MG ORAL TABLET,3203074,CDM,250,RC,,,outpatient,,,19.42,14.57,,15.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.81,15.54,
NF-PAPAYA ENZYME ORAL TABLET,3203076,CDM,250,RC,,,outpatient,,,12.8,9.6,,10.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.15,10.24,
NF-MAGNESIUM CITRATE 100 MG ORAL TABLET,3203077,CDM,250,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
"NF-METFORMIN HCL 1000MG ORAL TABLET, EXT",3203079,CDM,250,RC,,,outpatient,,,116.18,87.14,,92.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.75,92.94,
NF-IBUPROFEN 200MG ORAL TABLET,3203080,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-ENTRESTO 24MG-26MG ORAL TABLET,3203081,CDM,250,RC,,,outpatient,,,27.75,20.81,,22.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.17,22.2,
NF-ZANTAC 300 300MG ORAL TABLET,3203082,CDM,250,RC,,,outpatient,,,44.6,33.45,,35.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.95,35.68,
NF-BIOTIN ORAL TABLET 300MCG,3203083,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-CYANOCOBALAMIN POWDER,3203084,CDM,250,RC,,,outpatient,,,1417.1,1062.83,,1133.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,779.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,570.24,1133.68,
NF-ZOFRAN 4MG ORAL TABLET,3203085,CDM,250,RC,,,outpatient,,,114.33,85.75,,91.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.01,91.46,
NF-FOLIC ACID 1MG ORAL TABLET,3203086,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-MAGNESIUM OXIDE 400MG ORAL TABLET,3203087,CDM,250,RC,,,outpatient,,,0.54,0.41,,0.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.22,0.43,
"NF-POTASSIUM CHLORIDE 20MEQ ORAL TABLET,",3203088,CDM,250,RC,,,outpatient,,,2.04,1.53,,1.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.63,
NF-HYDROCODONE POLISTIREX-CHLORPHENIRAMI,3203089,CDM,250,RC,,,outpatient,,,5.94,4.46,,4.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.39,4.75,
NF-BENICAR HCT 40MG-12.5MG ORAL TABLET,3203090,CDM,250,RC,,,outpatient,,,16.69,12.52,,13.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,13.35,
NF-LEXAPRO 20MG ORAL TABLET,3203091,CDM,250,RC,,,outpatient,,,25.46,19.1,,20.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.25,20.37,
NF-GABAPENTIN 800MG ORAL TABLET,3203092,CDM,250,RC,,,outpatient,,,11.72,8.79,,9.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.72,9.38,
NF-SINEMET 25-100 25MG-100MG ORAL TABLET,3203093,CDM,250,RC,,,outpatient,,,3.37,2.53,,2.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.36,2.7,
NF-LISINOPRIL 30MG ORAL TABLET,3203094,CDM,250,RC,,,outpatient,,,5.57,4.18,,4.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.24,4.46,
NF-NEURONTIN SOLUTION 250MG/5ML,3203095,CDM,250,RC,,,outpatient,,,2.53,1.9,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.02,
NF-BRINTELLIX ORAL TABLET 20MG,3203096,CDM,250,RC,,,outpatient,,,42.85,32.14,,34.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.24,34.28,
NF-PRILOSEC CAP DR 20MG,3203097,CDM,250,RC,,,outpatient,,,23.51,17.63,,18.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.46,18.81,
NF-VALSARTAN 320MG ORAL TABLET,3203098,CDM,250,RC,,,outpatient,,,23.4,17.55,,18.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.42,18.72,
NF-CALCIUM MAGNESIUM ZINC WITH VITAMIN D,3203099,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
"NF-DILTIAZEM HCL 360MG ORAL TABLET, EXTE",3203100,CDM,250,RC,,,outpatient,,,17.27,12.95,,13.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.95,13.82,
NF-CERTAVITE SENIOR ORAL TABLET,3203101,CDM,250,RC,,,outpatient,,,0.47,0.35,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-TRULICITY 1.5MG/0.5ML SUBCUTANEOUS SO,3203102,CDM,250,RC,,,outpatient,,,1276.06,957.05,,1020.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,513.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,638.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,638.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,638.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,638.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,701.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,513.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1020.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,957.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,513.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1020.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,513.49,1020.85,
NF-DICLOFENAC NA ORAL TAB EC 25MG,3203103,CDM,250,RC,,,outpatient,,,1.7,1.28,,1.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.36,
PREMPRO ORAL TABLET 0.625MG-2.5MG 28 pac,3203104,CDM,637,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
NF-COVARYX TAB 1.25MG-2.5MG,3203106,CDM,250,RC,,,outpatient,,,3.55,2.66,,2.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.43,2.84,
BRIDION INTRAVENOUS SOLUTION 200MG/2ML,3203107,CDM,250,RC,,,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,182.4,
NF-SIMVASTATIN 80MG ORAL TABLET,3203108,CDM,250,RC,,,outpatient,,,18.21,13.66,,14.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.33,14.57,
NF-ZOLOFT 50MG ORAL TABLET,3203109,CDM,250,RC,,,outpatient,,,12.32,9.24,,9.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.96,9.86,
"NF-PRILOSEC 40MG ORAL CAPSULE, DELAYED R",3203110,CDM,250,RC,,,outpatient,,,34.46,25.85,,27.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.87,27.57,
NF-MEDI-MECLIZINE 25MG ORAL TABLET,3203111,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-GOOD NEIGHBOR PHARMACY STOOL SOFTNER,3203112,CDM,250,RC,,,outpatient,,,0.32,0.24,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-GERITOL COMPLETE ORAL TABLET,3203113,CDM,250,RC,,,outpatient,,,4.35,3.26,,3.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.75,3.48,
NF-MOTRIN 800MG ORAL TABLET,3203114,CDM,250,RC,,,outpatient,,,1.44,1.08,,1.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.58,1.15,
NF-VITAMIN B12 1000MCG/1ML INTRAMUSCULAR,3203115,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-ADDERALL 30MG ORAL TABLET,3203116,CDM,250,RC,,,outpatient,,,20.45,15.34,,16.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.23,16.36,
NF-SODIUM CHLORIDE 1 GM ORAL TABLET,3203117,CDM,250,RC,,,outpatient,,,0.19,0.14,,0.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.15,
NF-HYDROCHLOROTHIAZIDE 25MG ORAL TABLET,3203118,CDM,250,RC,,,outpatient,,,0.56,0.42,,0.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.45,
NF-CITALOPRAM 10MG ORAL TABLET,3203119,CDM,250,RC,,,outpatient,,,8.91,6.68,,7.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.59,7.13,
NF-HYDROCODONE BITARTRATE-ACETAMINOPHEN,3203120,CDM,250,RC,,,outpatient,,,7.2,5.4,,5.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.9,5.76,
NF-BYSTOLIC ORAL TABLET 20MG,3203121,CDM,250,RC,,,outpatient,,,15.11,11.33,,12.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.08,12.09,
NF-ZOFRAN ODT ORAL DISINTEGRATING TAB 8M,3203122,CDM,250,RC,,,outpatient,,,167.68,125.76,,134.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,83.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.47,134.14,
NF-ROPINIROLE HYDROCHLORIDE TAB ER 8MG,3203123,CDM,250,RC,,,outpatient,,,30.36,22.77,,24.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.22,24.29,
NF-LOFIBRA ORAL TABLET 160MG,3203124,CDM,250,RC,,,outpatient,,,20.57,15.43,,16.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.28,16.46,
NF-NALFON CAP 400MG,3203125,CDM,250,RC,,,outpatient,,,11.84,8.88,,9.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.76,9.47,
NF-THYROID TAB 60MG,3203126,CDM,250,RC,,,outpatient,,,1.98,1.49,,1.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.58,
NF-MUCINEX D ORAL TABLET ER 600MG-60MG,3203127,CDM,250,RC,,,outpatient,,,2.27,1.7,,1.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.82,
NF-ARMOUR THYROID 90MG ORAL TABLET,3203128,CDM,250,RC,,,outpatient,,,3.33,2.5,,2.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.34,2.66,
"NF-VITAMIN B12 1000MCG ORAL TABLET, EXTE",3203129,CDM,250,RC,,,outpatient,,,0.39,0.29,,0.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.31,
NF-TAMSULOSIN HCL 0.4MG ORAL CAPSULE,3203130,CDM,250,RC,,,outpatient,,,15.57,11.68,,12.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.27,12.46,
NF-MULTIVITAMIN ORAL TABLET,3203131,CDM,250,RC,,,outpatient,,,0.05,0.04,,0.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.04,
NF-CYANOCOBALAMIN POWDER,3203132,CDM,250,RC,,,outpatient,,,1417.1,1062.83,,1133.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,708.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,779.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1133.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,570.24,1133.68,
NF-TRESIBA SUBQ SOLN 100U/1ML,3203133,CDM,250,RC,,,outpatient,,,131.38,98.54,,105.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.87,105.1,
NF-NYSTATIN 100000U/1GM TOPICAL APPLICAT,3203134,CDM,250,RC,,,outpatient,,,4.14,3.11,,3.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.67,3.31,
PR US VENOUS DOPPLER-UNILAT - LEFT,4110043,CDM,972,RC,9397126LT,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
PR US BREAST UNILATERAL -RT LIMITED,4110044,CDM,972,RC,7664226RT,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-METOPROLOL SUCCINATE 50MG ORAL TABLET,3203137,CDM,250,RC,,,outpatient,,,4.73,3.55,,3.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.9,3.78,
NF-ISOSORBIDE DINITRATE 30MG ORAL TABLET,3203138,CDM,250,RC,,,outpatient,,,4.85,3.64,,3.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.95,3.88,
NF-FENOFIBRATE 54MG ORAL TABLET,3203139,CDM,250,RC,,,outpatient,,,2.93,2.2,,2.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,2.34,
NF-LITHIUM CARBONATE 300MG ORAL TABLET,3203140,CDM,250,RC,,,outpatient,,,0.96,0.72,,0.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.39,0.77,
NF-VALTREX 500MG ORAL TABLET,3203141,CDM,250,RC,,,outpatient,,,44.2,33.15,,35.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.79,35.36,
"NF-ALPRAZOLAM 1MG ORAL TABLET, EXTENDED",3203142,CDM,250,RC,,,outpatient,,,9.89,7.42,,7.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.98,7.91,
NF-OMEGA-3 KRILL OIL 27MG-45MG-300MG-90M,3203143,CDM,250,RC,,,outpatient,,,1.33,1,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.06,
NF-LEVOTHYROXINE 50MCG ORAL TABLET,3203144,CDM,250,RC,,,outpatient,,,1.37,1.03,,1.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.55,1.1,
NF-SERTRALINE 25MG ORAL TABLET,3203145,CDM,250,RC,,,outpatient,,,10.04,7.53,,8.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.04,8.03,
NF-PEPCID 20MG ORAL TABLET,3203146,CDM,250,RC,,,outpatient,,,42.89,32.17,,34.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.26,34.31,
NF-EPIPEN 2-PAK AUTO-INJECTOR 1 MG/1 ML,3203147,CDM,250,RC,,,outpatient,,,438.82,329.12,,351.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,219.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,329.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,351.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,176.58,351.06,
NF-BENZTROPINE MESYLATE 2MG ORAL TABLET,3203148,CDM,637,RC,,,outpatient,,,1.92,1.44,,1.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.77,1.54,
NF-ZYPREXA 20MG ORAL TABLET,3203149,CDM,250,RC,,,outpatient,,,163.75,122.81,,131,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.89,131,
NF-GUAIFENESIN 100MG/5ML ORAL SYRUP,3203150,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-AMANTADINE HCL 100MG ORAL CAPSULE,3203151,CDM,250,RC,,,outpatient,,,13.81,10.36,,11.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.56,11.05,
NF-MIRALAX 17GM/DOSE ORAL POWDER FOR SOL,3203152,CDM,250,RC,,,outpatient,,,0.37,0.28,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
NF-GUANFACINE HCL 2MG ORAL TABLET,3203153,CDM,250,RC,,,outpatient,,,4.35,3.26,,3.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.75,3.48,
NF-OMNARIS NASAL SPRAY 50MCG/1ACT,3203154,CDM,250,RC,,,outpatient,,,75.66,56.75,,60.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.45,60.53,
NF-INVEGA EXTENDED RELEASE TABLET 9MG,3203155,CDM,250,RC,,,outpatient,,,207.36,155.52,,165.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,103.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,83.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,83.44,165.89,
NF-ICAPS LUTEIN & ZEAXANTHIN ORAL TABLET,3203156,CDM,250,RC,,,outpatient,,,0.64,0.48,,0.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.26,0.51,
NF-PYRIDOSTIGMINE BROMIDE ORAL TABLET 60,3203157,CDM,250,RC,,,outpatient,,,4.72,3.54,,3.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.9,3.78,
NF-FLUNISOLIDE NASAL SPRAY 0.025MG/ACTUA,3203158,CDM,250,RC,,,outpatient,,,18.32,13.74,,14.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.37,14.66,
NF-GABAPENTIN 600MG ORAL TABLET,3203159,CDM,250,RC,,,outpatient,,,10.38,7.79,,8.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.18,8.3,
NF-NEURONTIN 300MG ORAL CAPSULE,3203161,CDM,250,RC,,,outpatient,,,6.76,5.07,,5.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.72,5.41,
"NF-CARBAMAZEPINE 100MG ORAL TABLET, CHEW",3203162,CDM,250,RC,,,outpatient,,,0.86,0.65,,0.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.35,0.69,
NF-MACROBID 100MG ORAL CAPSULE,3203163,CDM,250,RC,,,outpatient,,,20.41,15.31,,16.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.21,16.33,
NF-VERAPAMIL HCL 80MG ORAL TABLET,3203164,CDM,250,RC,,,outpatient,,,1.98,1.49,,1.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.58,
NF-AMLODIPINE BESYLATE 10MG ORAL TABLET,3203165,CDM,250,RC,,,outpatient,,,9.31,6.98,,7.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.75,7.45,
NF-LISINOPRIL 5MG ORAL TABLET,3203166,CDM,250,RC,,,outpatient,,,3.52,2.64,,2.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.42,2.82,
NF-METOPROLOL TARTRATE 50MG ORAL TABLET,3203167,CDM,250,RC,,,outpatient,,,2.01,1.51,,1.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.81,1.61,
NF-TORSEMIDE 20MG ORAL TABLET,3203168,CDM,250,RC,,,outpatient,,,2.9,2.18,,2.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.17,2.32,
NF-UNISOM TABLET 25MG,3203169,CDM,250,RC,,,outpatient,,,1.26,0.95,,1.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.51,1.01,
NF-FOLBEE PLUS TABLET,3203170,CDM,250,RC,,,outpatient,,,1.96,1.47,,1.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.79,1.57,
NF-AKWA TEARS OPHTHALMIC OINTMENT,3203171,CDM,250,RC,,,outpatient,,,4.1,3.08,,3.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.65,3.28,
NF-SEROPHENE 50MG ORAL TABLET,3203172,CDM,250,RC,,,outpatient,,,45.38,34.04,,36.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.26,36.3,
"NF-THEOPHYLLINE 400MG ORAL TABLET, EXTEN",3203173,CDM,250,RC,,,outpatient,,,5.02,3.77,,4.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.02,4.02,
NF-DANTROLENE SODIUM 50MG ORAL CAPSULE,3203174,CDM,250,RC,,,outpatient,,,6.4,4.8,,5.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.58,5.12,
MONTELUKAST SODIUM CHEW TAB 5MG,3203175,CDM,637,RC,,,outpatient,,,6.78,5.09,,5.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.73,5.42,
NF-AMLODIPINE BESYLATE 10MG ORAL TABLET,3203176,CDM,637,RC,,,outpatient,,,9.32,6.99,,7.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.75,7.46,
NF-BUMETANIDE 2MG ORAL TABLET,3203177,CDM,637,RC,,,outpatient,,,2.79,2.09,,2.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,2.23,
NF-DIPHENHYDRAMINE 50MG ORAL CAPSULE,3203178,CDM,250,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
RIZATRIPTAN BENZOATE ORAL TABLET 10MG,3203179,CDM,637,RC,,,outpatient,,,6.52,4.89,,5.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.22,
NF-GLIPIZIDE 5MG ORAL TABLET,3203180,CDM,637,RC,,,outpatient,,,1.4,1.05,,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.12,
NF-ATENOLOL/CHLORTHALIDONE TAB 100MG-25M,3203181,CDM,250,RC,,,outpatient,,,7.83,5.87,,6.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.15,6.26,
NF-ATENOLOL-CHLORTHALIDONE TAB 100MG-25M,3203182,CDM,250,RC,,,outpatient,,,3.17,2.38,,2.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.28,2.54,
"NF-DILTIAZEM 120MG ORAL CAPSULE, EXTENDE",3203183,CDM,250,RC,,,outpatient,,,12.84,9.63,,10.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.17,10.27,
NF-ZANAFLEX CAPSULE 4MG ORAL CAPSULE,3203184,CDM,250,RC,,,outpatient,,,22.85,17.14,,18.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.19,18.28,
"NF-COLACE 100MG ORAL CAPSULE, LIQUID FIL",3203185,CDM,250,RC,,,outpatient,,,1.9,1.43,,1.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.76,1.52,
NF-DULERA INH AER PWD 5MCG-200MCG/ACT,3203186,CDM,250,RC,,,outpatient,,,93.72,70.29,,74.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.71,74.98,
NF-AZOR ORAL TABLET 5MG-20MG,3203187,CDM,250,RC,,,outpatient,,,13.88,10.41,,11.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.59,11.1,
"NF-VENLAFAXINE HCL 37.5MG ORAL TABLET, E",3203188,CDM,250,RC,,,outpatient,,,15.24,11.43,,12.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.13,12.19,
NF-LEXAPRO 20MG ORAL TABLET,3203189,CDM,250,RC,,,outpatient,,,37.32,27.99,,29.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.02,29.86,
NF-LASIX 40MG ORAL TABLET,3203190,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
"NF-PANTOPRAZOLE SODIUM 40MG ORAL TABLET,",3203191,CDM,250,RC,,,outpatient,,,20.74,15.56,,16.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.35,16.59,
NF-GLIMEPIRIDE 1MG ORAL TABLET,3203192,CDM,250,RC,,,outpatient,,,1.49,1.12,,1.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.19,
NF-FENOFIBRATE ORAL TABLET 54MG,3203193,CDM,250,RC,,,outpatient,,,2.93,2.2,,2.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.18,2.34,
NF-ONCE DAILY MULTI-VITAMIN ORAL TABLET,3203194,CDM,250,RC,,,outpatient,,,0.42,0.32,,0.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.17,0.34,
NF-NEURONTIN 600MG ORAL TABLET,3203195,CDM,250,RC,,,outpatient,,,8.49,6.37,,6.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.79,
"NF-EFFEXOR XR 37.5MG ORAL CAPSULE, EXTEN",3203196,CDM,250,RC,,,outpatient,,,38.88,29.16,,31.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.65,31.1,
NF-GLYCERIN SUPPOSITORIES RECTAL SUPPOSI,3203197,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-PHILLIPS MILK OF MAGNESIA 400 MG/5 ML,3203198,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
"NF-AMITIZA 8MCG ORAL CAPSULE, LIQUID FIL",3203199,CDM,250,RC,,,outpatient,,,18.47,13.85,,14.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.43,14.78,
"NF-COLACE 100MG ORAL CAPSULE, LIQUID FIL",3203200,CDM,250,RC,,,outpatient,,,1.33,1,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.06,
NF-MECLIZINE HCL 12.5MG ORAL TABLET,3203201,CDM,250,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
"NF-ASPIRIN EC 325MG ORAL TABLET, ENTERIC",3203202,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
"NF-PRESERVISION AREDS ORAL CAPSULE, LIQU",3203203,CDM,250,RC,,,outpatient,,,0.84,0.63,,0.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.34,0.67,
NF-LEVSIN 0.125MG ORAL TABLET,3203204,CDM,250,RC,,,outpatient,,,3.44,2.58,,2.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.38,2.75,
NF-FENOFIBRATE ORAL TABLET 54MG,3203205,CDM,250,RC,,,outpatient,,,4.82,3.62,,3.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.94,3.86,
PR US NON VASCULAR EXT - LIMITED - LT,4110046,CDM,972,RC,7688226LT,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-COCONUT OIL OIL,3203207,CDM,250,RC,,,outpatient,,,0.37,0.28,,0.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.15,0.3,
NF-ADDERALL 20MG ORAL TABLET,3203208,CDM,250,RC,,,outpatient,,,20.45,15.34,,16.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.23,16.36,
NF-ZIKS HEMATOGEN 250MG-0.01MG-200MG-1 O,3203209,CDM,250,RC,,,outpatient,,,1.15,0.86,,0.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.46,0.92,
NF-HYDRALAZINE HCL ORAL TABLET 100MG,3203210,CDM,250,RC,,,outpatient,,,4.22,3.17,,3.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.7,3.38,
NF-HYOSCYAMINE 0.125MG ORAL TABLET,3203211,CDM,250,RC,,,outpatient,,,1.83,1.37,,1.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.74,1.46,
NF-SILENOR ORAL TABLET 3MG,3203213,CDM,250,RC,,,outpatient,,,54.41,40.81,,43.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.89,43.53,
NF-AMITRIPTYLINE HCL ORAL TABLET 100MG,3203214,CDM,250,RC,,,outpatient,,,9.4,7.05,,7.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.78,7.52,
NF-ASMANEX TWISTHALER INH PWD 0.22MG/1AC,3203215,CDM,250,RC,,,outpatient,,,1249.05,936.79,,999.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,624.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,686.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,502.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,999.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,502.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,502.62,999.24,
NF-BRIMONIDINE TARTRATE OPHTH SOLN 0.15%,3203216,CDM,250,RC,,,outpatient,,,115.32,86.49,,92.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.4,92.26,
ARMOUR THYROID TABLET 120MG,3203217,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
"NF-PANTOPRAZOLE SODIUM 40MG ORAL TABLET,",3203218,CDM,250,RC,,,outpatient,,,20.57,15.43,,16.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.28,16.46,
NF-METOPROLOL SUCCINATE 50MG ORAL TABLET,3203219,CDM,250,RC,,,outpatient,,,5.2,3.9,,4.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.09,4.16,
NF-ASPIRIN 325MG ORAL TABLET,3203220,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-ENBREL POWDER FOR INJ 25MG,3203221,CDM,250,RC,,,outpatient,,,2069.39,1552.04,,1655.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1034.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1138.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1552.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,832.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1655.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,832.72,1655.51,
NF-HYDROCHLOROTHIAZIDE CAP 12.5MG,3203222,CDM,250,RC,,,outpatient,,,1.57,1.18,,1.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.63,1.26,
NF-AMITIZA ORAL LIQUID FILLED CAPSULE 8M,3203223,CDM,250,RC,,,outpatient,,,24.44,18.33,,19.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.83,19.55,
NF-FISH OIL 500 MG ORAL CAPSULE,3203224,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-MOTRIN 600MG ORAL TABLET,3203225,CDM,250,RC,,,outpatient,,,0.98,0.74,,0.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.39,0.78,
NF-VALIUM 5MG ORAL TABLET,3203226,CDM,250,RC,,,outpatient,,,9.53,7.15,,7.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,7.62,
NF-LIPITOR 80MG ORAL TABLET,3203227,CDM,250,RC,,,outpatient,,,28.09,21.07,,22.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.3,22.47,
NF-BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50M,3203228,CDM,250,RC,,,outpatient,,,7.18,5.39,,5.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,5.74,
NF-PULMICORT FLEX 180MCG/1ACT INHALATION,3203229,CDM,250,RC,,,outpatient,,,695.12,521.34,,556.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,347.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,382.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,279.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,521.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,279.72,556.1,
NF-AMITRIPTYLINE HCL 75 MG ORAL TABLET,3203230,CDM,250,RC,,,outpatient,,,3.97,2.98,,3.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.6,3.18,
NF-EFFEXOR XR ORAL CAP ER 150MG,3203231,CDM,250,RC,,,outpatient,,,33.3,24.98,,26.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.4,26.64,
NF-VYVANSE CAP 50MG,3203232,CDM,250,RC,,,outpatient,,,25.77,19.33,,20.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.37,20.62,
NF-ARMOUR THYROID 30MG ORAL TABLET,3203233,CDM,250,RC,,,outpatient,,,0.25,0.19,,0.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.2,
"NF-ASPIRIN 325MG ORAL TABLET, ENTERIC CO",3203234,CDM,250,RC,,,outpatient,,,0.5,0.38,,0.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.4,
NF-NEVANAC 0.1% OPHTHALMIC SUSPENSION,3203235,CDM,250,RC,,,outpatient,,,333,249.75,,266.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,134,266.4,
NF-DAKIN\'S SOLUTION HALF STRENGTH 0.25%,3203236,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-GABAPENTIN 400 MG ORAL CAPSULE,3203237,CDM,250,RC,,,outpatient,,,5.88,4.41,,4.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,4.7,
NF-FLOMAX 0.4MG ORAL CAPSULE,3203238,CDM,250,RC,,,outpatient,,,30.64,22.98,,24.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.33,24.51,
NF-PRO-STAT 64 ORAL LIQUID,3203239,CDM,250,RC,,,outpatient,,,0.15,0.11,,0.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.12,
NF-ACETAMINOPHEN 500MG ORAL CAPSULE,3203240,CDM,250,RC,,,outpatient,,,0.06,0.05,,0.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.05,
NF-DANTROLENE SODIUM CAP 50MG,3203241,CDM,250,RC,,,outpatient,,,5.76,4.32,,4.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.32,4.61,
NF-SENNA 8.6MG ORAL TABLET,3203242,CDM,637,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-FLUOCINONIDE 0.05% TOPICAL APPLICATIO,3203243,CDM,637,RC,,,outpatient,,,5.99,4.49,,4.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.79,
NF-METOPROLOL TARTRATE 50MG ORAL TABLET,3203244,CDM,250,RC,,,outpatient,,,2.22,1.67,,1.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.89,1.78,
NF-LEVOTHROID 150MCG ORAL TABLET,3203245,CDM,250,RC,,,outpatient,,,3.33,2.5,,2.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.34,2.66,
NF-LISINOPRIL 2.5MG ORAL TABLET,3203246,CDM,250,RC,,,outpatient,,,2.37,1.78,,1.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.9,
NF-ROPINIROLE HCL 0.25MG ORAL TABLET,3203247,CDM,250,RC,,,outpatient,,,9.26,6.95,,7.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.73,7.41,
"NF-OMEPRAZOLE 40MG ORAL CAPSULE, DELAYED",3203248,CDM,250,RC,,,outpatient,,,27.37,20.53,,21.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.01,21.9,
NF-SPIRONOLACTONE 100MG ORAL TABLET,3203249,CDM,250,RC,,,outpatient,,,9.6,7.2,,7.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.86,7.68,
NF-APRESOLINE 50MG ORAL TABLET,3203250,CDM,250,RC,,,outpatient,,,2.4,1.8,,1.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.92,
NF-BREO ELLIPTA 200MCG-25MCG/1ACT INHALA,3203251,CDM,250,RC,,,outpatient,,,22.04,16.53,,17.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.87,17.63,
NF-TERAZOSIN HCL 2MG ORAL CAPSULE,3203252,CDM,250,RC,,,outpatient,,,5.76,4.32,,4.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.32,4.61,
PERMETHRIN TOPICAL CREAM 5%,3203253,CDM,637,RC,,,outpatient,,,146.4,109.8,,117.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.91,117.12,
NF-LISINOPRIL 10MG ORAL TABLET,3203254,CDM,250,RC,,,outpatient,,,3.68,2.76,,2.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.48,2.94,
NF-OPSUMIT 10MG ORAL TABLET,3203255,CDM,250,RC,,,outpatient,,,1116.66,837.5,,893.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,449.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,558.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,558.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,558.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,614.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,449.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,837.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,893.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,449.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,449.34,893.33,
NF-RANITIDINE HCL 150MG ORAL CAPSULE,3203256,CDM,250,RC,,,outpatient,,,5.46,4.1,,4.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.2,4.37,
"NF-OXYBUTYNIN CHLORIDE 15MG ORAL TABLET,",3203257,CDM,250,RC,,,outpatient,,,12.48,9.36,,9.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.02,9.98,
NF-VYVANSE 70MG ORAL CAPSULE,3203258,CDM,250,RC,,,outpatient,,,36.75,27.56,,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.79,29.4,
NF-LISINOPRIL 2.5MG ORAL TABLET,3203259,CDM,250,RC,,,outpatient,,,2.38,1.79,,1.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.96,1.9,
NF-TIZANIDINE HCL 4MG ORAL CAPSULE,3203260,CDM,250,RC,,,outpatient,,,12.72,9.54,,10.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.12,10.18,
NF-CLONAZEPAM 2MG ORAL TABLET,3203261,CDM,250,RC,,,outpatient,,,4.38,3.29,,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.76,3.5,
NF-AMITRIPTYLINE HCL 150MG ORAL TABLET,3203262,CDM,250,RC,,,outpatient,,,14.33,10.75,,11.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.77,11.46,
AMOXICILLIN/CLAVULANATE 250MG-62.5MG/5ML,3203264,CDM,637,RC,,,outpatient,,,108.85,81.64,,87.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.8,87.08,
PR US NON VASCULAR EXT - LIMITED - RT,4110050,CDM,972,RC,7688226RT,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
PROMETHAZINE 25MG/NSS 50ML,3203267,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-CLONIDINE HCL 0.2MG ORAL TABLET,3203268,CDM,250,RC,,,outpatient,,,1.2,0.9,,0.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.48,0.96,
NF-PEPCID 20MG ORAL TABLET,3203269,CDM,250,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
NF-ALBENZA ORAL TABLET 200MG,3203270,CDM,250,RC,,,outpatient,,,744.7,558.53,,595.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,299.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,409.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,595.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,299.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,595.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,299.67,595.76,
CHLORTHALIDONE TABLET 50MG,3203271,CDM,637,RC,,,outpatient,,,1.4,1.05,,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.56,1.12,
NF-CELEBREX 200MG ORAL CAPSULE,3203272,CDM,250,RC,,,outpatient,,,22.2,16.65,,17.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.93,17.76,
NF-NEXIUM CAP DR 40MG,3203273,CDM,250,RC,,,outpatient,,,37.14,27.86,,29.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.95,29.71,
NF-RESTASIS OPHTH EMULSION 0.05%,3203274,CDM,250,RC,,,outpatient,,,31.58,23.69,,25.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.71,25.26,
NF-CARTIA XT ORAL 24 HR CAP ER 120MG,3203275,CDM,250,RC,,,outpatient,,,4.43,3.32,,3.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.78,3.54,
NF-LATANOPROST OPHTH SOLN 0.005%,3203276,CDM,250,RC,,,outpatient,,,170.05,127.54,,136.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.43,136.04,
NF-HYDROCHLOROTHIAZIDE CAP 12.5MG,3203277,CDM,250,RC,,,outpatient,,,1.81,1.36,,1.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.45,
NF-NORVASC TAB 2.5MG,3203278,CDM,250,RC,,,outpatient,,,8.74,6.56,,6.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.52,6.99,
NF-ACETAMINOPHEN 500MG ORAL CAPSULE,3203279,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-ANORO ELLIPTA INH PWD 62.5MCG-25MCG/1,3203280,CDM,250,RC,,,outpatient,,,23.36,17.52,,18.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.4,18.69,
NF-PRO-STAT 64 SOLUTION,3203281,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
FUSION PLUS ORAL CAPSULE,3203282,CDM,637,RC,,,outpatient,,,1.24,0.93,,0.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.5,0.99,
NF-B COMPLEX TABLET,3203283,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-TRIMETHOPRIM ORAL TABLET 100MG,3203284,CDM,250,RC,,,outpatient,,,2.53,1.9,,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.02,2.02,
NF-MEGACE ES 625MG/5ML ORAL SUSPENSION,3203285,CDM,250,RC,,,outpatient,,,27.07,20.3,,21.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.89,21.66,
NF-LEVOCETIRIZINE DIHYDROCHLORIDE 5MG OR,3203286,CDM,250,RC,,,outpatient,,,11.38,8.54,,9.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.58,9.1,
NF-HYDROXYZINE HCL 50MG ORAL TABLET,3203287,CDM,250,RC,,,outpatient,,,4.15,3.11,,3.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.67,3.32,
NF-PRAVASTATIN SODIUM 80MG ORAL TABLET,3203288,CDM,250,RC,,,outpatient,,,17.74,13.31,,14.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.14,14.19,
NF-IRBESARTAN ORAL TABLET 75MG,3203289,CDM,250,RC,,,outpatient,,,10.8,8.1,,8.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.35,8.64,
NF-PREPLUS ORAL TABLET,3203290,CDM,250,RC,,,outpatient,,,1.82,1.37,,1.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.46,
NF-VYVANSE CAP 40MG,3203291,CDM,250,RC,,,outpatient,,,36.75,27.56,,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.79,29.4,
NF-VIMPAT ORAL TABLET 100MG,3203292,CDM,250,RC,,,outpatient,,,50.83,38.12,,40.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.45,40.66,
NF-REVLIMID ORAL CAPSULE 25MG,3203293,CDM,250,RC,,,outpatient,,,2383.72,1787.79,,1906.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,959.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1191.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1191.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1191.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1191.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1311.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1906.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,959.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1906.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1787.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1906.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1906.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,959.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1906.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,959.21,1906.98,
NF-SIMVASTATIN 80MG ORAL TABLET,3203294,CDM,250,RC,,,outpatient,,,18.1,13.58,,14.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.28,14.48,
NF-LEVAQUIN 750MG ORAL TABLET,3203295,CDM,250,RC,,,outpatient,,,101.79,76.34,,81.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.96,81.43,
"NF-DILTIAZEM HCL 360MG ORAL CAPSULE, EXT",3203296,CDM,250,RC,,,outpatient,,,8.67,6.5,,6.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.49,6.94,
NF-ADIPEX-P TAB 37.5MG,3203297,CDM,250,RC,,,outpatient,,,7.15,5.36,,5.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.88,5.72,
NF-DUEXIS ORAL TABLET 26.6MG-800MG,3203298,CDM,250,RC,,,outpatient,,,80.54,60.41,,64.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.41,64.43,
NF-ZOLPIDEM TARTRATE 10MG ORAL TABLET,3203299,CDM,250,RC,,,outpatient,,,16.92,12.69,,13.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.81,13.54,
CHLORZOXAZONE ORAL TABLET 500MG,3203300,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
MRI MULTIHANCE 10ML,4200029,CDM,636,RC,A9577,HCPCS,both,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,100,
NF-MORPHINE SULFATE 30MG ORAL TABLET,3203302,CDM,250,RC,,,outpatient,,,8.78,6.59,,7.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.53,7.02,
"NF-CARDIZEM CD 120MG ORAL CAPSULE, EXTEN",3203303,CDM,250,RC,,,outpatient,,,108.11,81.08,,86.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.5,86.49,
NF-SENOKOT S 50MG-8.6MG ORAL TABLET,3203304,CDM,250,RC,,,outpatient,,,2.06,1.55,,1.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.83,1.65,
NF-SPIRONOLACTONE 50MG ORAL TABLET,3203305,CDM,637,RC,,,outpatient,,,3.01,2.26,,2.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.41,
NF-SPIRONOLACTONE 50MG ORAL TABLET,3203306,CDM,637,RC,,,outpatient,,,3.02,2.27,,2.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.22,2.42,
NF-MICROZIDE 12.5MG ORAL CAPSULE,3203307,CDM,250,RC,,,outpatient,,,5.19,3.89,,4.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.09,4.15,
NF-PROVENTIL HFA 0.09MG/1INH INHALATION,3203308,CDM,250,RC,,,outpatient,,,47.16,35.37,,37.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.98,37.73,
NF-OXYCODONE HCL 30MG ORAL TABLET,3203309,CDM,250,RC,,,outpatient,,,13.28,9.96,,10.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.34,10.62,
CARBAMAZEPINE SUSPENSION 100MG/5ML,3203310,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-CALCIUM/VITAMIN D 600 MG-200 IU ORAL,3203311,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
OMEPRAZOLE DELAYED-RELEASE CAPSULE 40MG,3203312,CDM,637,RC,,,outpatient,,,8.15,6.11,,6.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.28,6.52,
NF-PILOCARPINE HCL TAB 5MG,3203313,CDM,250,RC,,,outpatient,,,5.63,4.22,,4.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.5,
NF-AUBAGIO ORAL TABLET 14MG,3203314,CDM,250,RC,,,outpatient,,,904.79,678.59,,723.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,364.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,452.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,452.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,452.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,452.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,497.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,364.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,364.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,723.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,723.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,364.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,723.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,364.09,723.83,
NF-FLUOCINONIDE 0.05% TOPICAL APPLICATIO,3203315,CDM,250,RC,,,outpatient,,,5.99,4.49,,4.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.79,
NF-IPRATROPIUM BROMIDE-ALBUTEROL SULFATE,3203316,CDM,250,RC,,,outpatient,,,2.69,2.02,,2.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.08,2.15,
NF-FLUTICASONE PROPIONATE OINT 0.005%,3203318,CDM,250,RC,,,outpatient,,,4.9,3.68,,3.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.97,3.92,
NF-FOLIC ACID 1MG ORAL TABLET,3203319,CDM,250,RC,,,outpatient,,,1.33,1,,1.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.54,1.06,
NF-PHENERGAN 25MG ORAL TABLET,3203320,CDM,250,RC,,,outpatient,,,2.79,2.09,,2.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,2.23,
NF-VITAMIN E CAPSULE 100IU,3203321,CDM,250,RC,,,outpatient,,,0.09,0.07,,0.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.07,
NF-TRIBENZOR ORAL TABLET 5-12.5-20MG,3203322,CDM,250,RC,,,outpatient,,,29.3,21.98,,23.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.79,23.44,
NF-ADULT PROBIOTIC ORAL CAPSULE,3203323,CDM,250,RC,,,outpatient,,,1.82,1.37,,1.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.46,
NF-OCUVEL NA ORAL CAPSULE,3203324,CDM,250,RC,,,outpatient,,,39.41,29.56,,31.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.86,31.53,
NF-FENOFIBRATE 48MG ORAL TABLET,3203325,CDM,250,RC,,,outpatient,,,7.07,5.3,,5.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.84,5.66,
NF-ADDERALL XR CAP ER 30MG,3203326,CDM,250,RC,,,outpatient,,,21.09,15.82,,16.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.49,16.87,
NF-MERCAPTOPURINE ORAL TABLET 50MG,3203327,CDM,250,RC,,,outpatient,,,27.94,20.96,,22.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.24,22.35,
TOPIRAMATE ORAL TABLET 50MG,3203328,CDM,637,RC,,,outpatient,,,18.34,13.76,,14.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.38,14.67,
NF-CELECOXIB CAP 100MG,3203329,CDM,250,RC,,,outpatient,,,24.9,18.68,,19.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.02,19.92,
NF-LEVAQUIN ORAL TABLET 750MG,3203330,CDM,250,RC,,,outpatient,,,81.21,60.91,,64.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.68,64.97,
"NF-VITAMIN D3 2000 IU ORAL CAPSULE, LIQU",3203331,CDM,250,RC,,,outpatient,,,0.25,0.19,,0.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.2,
NATURE-THROID ORAL TABLET 65MG,3203333,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-BACID 500 MILLION ORG ORAL CAPSULE,3203334,CDM,250,RC,,,outpatient,,,3.4,2.55,,2.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.37,2.72,
NF-TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5M,3203335,CDM,250,RC,,,outpatient,,,2.41,1.81,,1.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.93,
NF-ZEGERID 20MG-1100MG ORAL CAPSULE,3203336,CDM,250,RC,,,outpatient,,,449,336.75,,359.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,180.68,359.2,
NF-FLORASTOR CAPSULE 250MG,3203337,CDM,250,RC,,,outpatient,,,3.95,2.96,,3.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.59,3.16,
NF-ASTEPRO NASAL SPRAY 205.5MCG/1ACT,3203338,CDM,250,RC,,,outpatient,,,22.9,17.18,,18.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.21,18.32,
NF-CHILDREN\'S ZYRTEC 5MG/5ML ORAL SOLUT,3203339,CDM,250,RC,,,outpatient,,,0.34,0.26,,0.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.27,
"NF-NEXIUM 40MG ORAL CAPSULE, DELAYED REL",3203340,CDM,250,RC,,,outpatient,,,53.01,39.76,,42.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,42.41,
NF-ONGLYZA 5MG ORAL TABLET,3203341,CDM,250,RC,,,outpatient,,,36.96,27.72,,29.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.87,29.57,
NF-VYTORIN 10MG-40MG ORAL TABLET,3203342,CDM,250,RC,,,outpatient,,,18.76,14.07,,15.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.55,15.01,
NF-URIBEL 0.12MG-118MG-10MG-36 ORAL CAPS,3203343,CDM,250,RC,,,outpatient,,,11.27,8.45,,9.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.54,9.02,
NF-LEVOTHYROXINE SODIUM POWDER,3203344,CDM,250,RC,,,outpatient,,,2738.22,2053.67,,2190.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1101.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1369.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1369.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1369.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1369.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1506.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2190.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1101.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2190.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2053.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2190.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2190.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1101.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2190.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1101.86,2190.58,
NF-KETOROLAC TROMETHAMINE 0.5% OPHTHALMI,3203345,CDM,250,RC,,,outpatient,,,79.08,59.31,,63.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.82,63.26,
NF-DUREZOL 0.05% OPHTHALMIC EMULSION,3203346,CDM,250,RC,,,outpatient,,,135.46,101.6,,108.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.51,108.37,
NF-DIOVAN HCT ORAL TABLET 80MG-12.5MG,3203347,CDM,250,RC,,,outpatient,,,28.31,21.23,,22.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.39,22.65,
NF-POTASSIUM 99 MG ORAL TABLET,3203348,CDM,637,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-CALCIUM/MAGNESIUM/ZINC 250 MG-125 MG-,3203349,CDM,250,RC,,,outpatient,,,0.12,0.09,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-MULTIVITAMIN ORAL TABLET,3203350,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-CLOBAZAM SUSP 2.5MG/1ML,3203351,CDM,250,RC,,,outpatient,,,28.19,21.14,,22.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.34,22.55,
NF-DIPYRIDAMOLE 75MG ORAL TABLET,3203352,CDM,250,RC,,,outpatient,,,4.66,3.5,,3.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.88,3.73,
NF-DETROL ORAL TABLET 2MG,3203353,CDM,250,RC,,,outpatient,,,27.51,20.63,,22.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.07,22.01,
NF-MINERAL OIL LIGHT OIL,3203354,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
"NF-B-COMPLEX-100 ORAL TABLET, EXTENDED R",3203355,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
"NF-COENZYME Q10 200 MG ORAL CAPSULE, LIQ",3203356,CDM,250,RC,,,outpatient,,,2.8,2.1,,2.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.13,2.24,
NF-MEVACOR 40MG ORAL TABLET,3203357,CDM,250,RC,,,outpatient,,,20.97,15.73,,16.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.44,16.78,
NF-LACTOBACILLUS COMBINATION CAP,3203358,CDM,250,RC,,,outpatient,,,7.03,5.27,,5.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.83,5.62,
"NF-TUMS 500MG ORAL TABLET, CHEWABLE",3203359,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
NF-PAMELOR 25MG ORAL CAPSULE,3203360,CDM,250,RC,,,outpatient,,,148.3,111.23,,118.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.68,118.64,
NF-PENNSAID 2% TOPICAL APPLICATION SOLUT,3203361,CDM,250,RC,,,outpatient,,,64.65,48.49,,51.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.02,51.72,
NF-BUMEX 1MG ORAL TABLET,3203362,CDM,250,RC,,,outpatient,,,3.25,2.44,,2.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.31,2.6,
NF-SIROLIMUS 1MG ORAL TABLET,3203363,CDM,250,RC,,,outpatient,,,62.71,47.03,,50.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.23,50.17,
NF-DAPSONE 100MG ORAL TABLET,3203366,CDM,250,RC,,,outpatient,,,12.43,9.32,,9.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5,9.94,
NF-AMLODIPINE BESYLATE 10MG ORAL TABLET,3203367,CDM,250,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
NF-GABAPENTIN 400MG ORAL TABLET,3203368,CDM,250,RC,,,outpatient,,,1.76,1.32,,1.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.71,1.41,
NF-MULTAQ 400MG ORAL TABLET,3203369,CDM,250,RC,,,outpatient,,,46.4,34.8,,37.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.67,37.12,
NF-TRAMADOL HCL 50MG ORAL TABLET,3203370,CDM,250,RC,,,outpatient,,,3.08,2.31,,2.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.24,2.46,
NF-LOPRESSOR 50MG ORAL TABLET,3203371,CDM,250,RC,,,outpatient,,,4.22,3.17,,3.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.7,3.38,
NF-GERITOL COMPLETE ORAL TABLET,3203372,CDM,250,RC,,,outpatient,,,5.7,4.28,,4.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.29,4.56,
NF-CHLORTHALIDONE 25MG ORAL TABLET,3203373,CDM,250,RC,,,outpatient,,,4.46,3.35,,3.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,3.57,
NF-FERGON 240 MG ORAL TABLET,3203374,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-HYDRALAZINE HCL 100MG ORAL TABLET,3203376,CDM,250,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
NF-SPIRIVA RESPIMAT 1.25MCG/1ACT INHALAT,3203377,CDM,250,RC,,,outpatient,,,378.44,283.83,,302.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.28,302.75,
STREPTOMYCIN 1GM,3203378,CDM,250,RC,,,outpatient,,,83.25,62.44,,66.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.5,66.6,
NF-BENAZEPRIL HCL ORAL TABLET 40MG,3203379,CDM,250,RC,,,outpatient,,,4.46,3.35,,3.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,3.57,
NF-REQUIP TAB 2MG,3203380,CDM,250,RC,,,outpatient,,,23.76,17.82,,19.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.56,19.01,
PHENOBARBITAL TAB 32.4MG,3203381,CDM,637,RC,,,outpatient,,,1.71,1.28,,1.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.69,1.37,
NF-TRIBENZOR ORAL TABLET 5-12.5-40MG,3203382,CDM,250,RC,,,outpatient,,,37.03,27.77,,29.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.9,29.62,
NF-PROMETHAZINE HCL 12.5MG ORAL TABLET,3203383,CDM,250,RC,,,outpatient,,,1.81,1.36,,1.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.73,1.45,
"NF-ZOFRAN ODT 8MG ORAL TABLET, DISINTEGR",3203384,CDM,250,RC,,,outpatient,,,162.25,121.69,,129.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.29,129.8,
NF-PEPCID 20MG ORAL TABLET,3203385,CDM,250,RC,,,outpatient,,,42.89,32.17,,34.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.26,34.31,
NF-SOMA 250MG ORAL TABLET,3203386,CDM,250,RC,,,outpatient,,,38.99,29.24,,31.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.19,
NF-ADVAIR HFA 230/21 230MCG-21MCG/1ACT I,3203387,CDM,250,RC,,,outpatient,,,162.84,122.13,,130.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.53,130.27,
NF-LAMOTRIGINE DISINTEGRATING TABLET 200,3203388,CDM,250,RC,,,outpatient,,,44.76,33.57,,35.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.01,35.81,
NF-TANDEM F CAP 162MG-1MG-115.2MG,3203389,CDM,250,RC,,,outpatient,,,1.51,1.13,,1.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.61,1.21,
NF-TRACLEER 62.5MG ORAL TABLET,3203390,CDM,250,RC,,,outpatient,,,684.43,513.32,,547.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,376.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,275.41,547.54,
"NF-PREVACID 30MG ORAL CAPSULE, DELAYED R",3203391,CDM,250,RC,,,outpatient,,,22.19,16.64,,17.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.93,17.75,
NF-FERROUS GLUCONATE ORAL TABLET 324MG,3203393,CDM,250,RC,,,outpatient,,,0.27,0.2,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-EFFEXOR-XR CAP ER 37.5MG,3203394,CDM,250,RC,,,outpatient,,,18.91,14.18,,15.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.61,15.13,
NF-TRESIBA 200U/1ML SUBCUTANEOUS SOLUTIO,3203395,CDM,250,RC,,,outpatient,,,262.76,197.07,,210.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.73,210.21,
NF-CHLORPROMAZINE HCL TAB 10MG,3203396,CDM,250,RC,,,outpatient,,,24.53,18.4,,19.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.87,19.62,
NF-ENTRESTO ORAL TABLET 49MG-51MG,3203397,CDM,250,RC,,,outpatient,,,29.94,22.46,,23.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.05,23.95,
NF-SUDAFED CONGESTION ORAL TABLET 30MG,3203398,CDM,250,RC,,,outpatient,,,0.82,0.62,,0.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.33,0.66,
NF-GABAPENTIN 600MG ORAL TABLET,3203399,CDM,637,RC,,,outpatient,,,14.51,10.88,,11.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.84,11.61,
NF-ADDERALL ORAL TABLET 10MG,3203400,CDM,250,RC,,,outpatient,,,12.91,9.68,,10.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.19,10.33,
NF-UCERIS ORAL EXTENDED RELEASE TABLET 9,3203401,CDM,250,RC,,,outpatient,,,238.66,179,,190.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.04,190.93,
NF-CYCLOBENZAPRINE 10MG ORAL TABLET,3203402,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-AMITRIPTYLINE 25MG ORAL TABLET,3203403,CDM,250,RC,,,outpatient,,,2.59,1.94,,2.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.04,2.07,
NF-PREMARIN 0.625MG ORAL TABLET,3203404,CDM,250,RC,,,outpatient,,,6.06,4.55,,4.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.44,4.85,
NF-MAGNESIUM OXIDE 400MG ORAL TABLET,3203405,CDM,250,RC,,,outpatient,,,0.42,0.32,,0.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.17,0.34,
"NF-TYLENOL ARTHRITIS 650MG ORAL TABLET,",3203406,CDM,250,RC,,,outpatient,,,0.4,0.3,,0.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.32,
NF-MAGNESIUM OXIDE 400MG ORAL TABLET,3203408,CDM,250,RC,,,outpatient,,,0.31,0.23,,0.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.25,
"NF-KLOR-CON M20 20MEQ ORAL TABLET, EXTEN",3203409,CDM,250,RC,,,outpatient,,,2.32,1.74,,1.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.93,1.86,
NF-HYDROCHLOROTHIAZIDE 12.5MG ORAL TABLE,3203410,CDM,250,RC,,,outpatient,,,6.1,4.58,,4.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.45,4.88,
NF-CARVEDILOL 6.25MG ORAL TABLET,3203411,CDM,250,RC,,,outpatient,,,21.74,16.31,,17.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.75,17.39,
NF-LOSARTAN POTASSIUM-HYDROCHLOROTHIAZID,3203412,CDM,250,RC,,,outpatient,,,9.26,6.95,,7.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.73,7.41,
NF-POTASSIUM CHLORIDE 10MEQ ORAL CAPSULE,3203413,CDM,250,RC,,,outpatient,,,2.15,1.61,,1.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.87,1.72,
NF-LAMICTAL 25MG ORAL TABLET,3203414,CDM,250,RC,,,outpatient,,,48.09,36.07,,38.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.35,38.47,
NF-VITAMIN B12 500MCG ORAL TABLET,3203415,CDM,250,RC,,,outpatient,,,0.17,0.13,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-LOVASTATIN 40MG ORAL TABLET,3203416,CDM,250,RC,,,outpatient,,,15.01,11.26,,12.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12.01,
NF-KAYEXALATE PWD FOR SUSP,3203417,CDM,250,RC,,,outpatient,,,7.46,5.6,,5.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,5.97,
NF-GLUCOS-AMINE ORAL CAPSULE 500MG,3203418,CDM,250,RC,,,outpatient,,,0.56,0.42,,0.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.45,
LEVOFLOXACIN ORAL TABLET 750MG,3203419,CDM,637,RC,,,outpatient,,,133.49,100.12,,106.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.72,106.79,
NF-COSOPT PF OPHTH SOLN 2%-0.5%,3203420,CDM,250,RC,,,outpatient,,,6.33,4.75,,5.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.55,5.06,
NF-TRINTELLIX ORAL TABLET 10MG,3203421,CDM,250,RC,,,outpatient,,,47.09,35.32,,37.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,37.67,
NF-AMILORIDE HCL/HCTZ TABLET 5MG-50MG,3203422,CDM,250,RC,,,outpatient,,,4.29,3.22,,3.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.73,3.43,
NF-Trintellix Oral Tablet 10MG,3203423,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
PR CT CHEST LD CHEST WO SCREEN,4310074,CDM,972,RC,7127126,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
SODIUM CHLORIDE 1000ML BOLUS,3203425,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
SODIUM CHLORIDE,3203426,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
SODIUM CHLORIDE,3203429,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-SEROQUEL XR ORAL TAB ER 400MG,3203430,CDM,250,RC,,,outpatient,,,77.71,58.28,,62.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.27,62.17,
NF-PHENERGAN INJ SOLN 25MG/1ML,3203431,CDM,250,RC,,,outpatient,,,9.84,7.38,,7.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.96,7.87,
NF-BRIMONIDINE TARTRATE OPHTH SOLN 0.2%,3203432,CDM,250,RC,,,outpatient,,,13.49,10.12,,10.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.79,
NF-Potassium Chloride Oral Cap ER 10MEQ,3203433,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Jardiance Oral Tablet 25MG,3203434,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Methotrexate Oral Tablet 2.5MG,3203435,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Jardiance Oral Tablet 25MG,3203436,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Toujeo Subcutaneous Solution 300U/1ML,3203437,CDM,250,RC,,,outpatient,,,331,248.25,,264.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.19,264.8,
NF-buPROPion HCl Oral Tab ER 150MG,3203438,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-busPIRone Oral Tablet 15MG,3203439,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-clonazePAM Oral Tablet 1MG,3203440,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Sprintec Tablet,3203441,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Eliquis Oral Tablet 5MG,3203443,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
PAROXETINE HCL ORAL TABLET 10MG,3203444,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Diclofenac Sodium Topical Gel 3%,3203445,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-PriLOSEC Capsule 20MG,3203447,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-VESIcare Oral Tablet 10MG,3203448,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-ZyrTEC Oral Chewable Tablet 10MG,3203449,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Co-Q-10 Oral Liquid Capsule 200MG,3203450,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Breo Ellipta Inhalation Powder,3203453,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE,3203454,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Xifaxan Oral Tablet 550MG,3203455,CDM,637,RC,,,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.32,108,
NF-guanFACINE HCl Tablet 2MG,3203456,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Eliquis Oral Tablet 2.5MG,3203458,CDM,637,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-SEROquel Oral Tablet 400MG,3203459,CDM,637,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
NF-Epipen Auto-Injector Kit 0.3MG/0.3ML,3203461,CDM,250,RC,,,outpatient,,,1351,1013.25,,1080.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,743.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,543.64,1080.8,
NF-chlorproMAZINE HCl Tablet 10MG,3203462,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
ETODOLAC TABLET 400MG,3203464,CDM,637,RC,,,outpatient,,,5.43,4.07,,4.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,4.34,
NF-Entresto Oral Tablet 24MG-26MG,3203465,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-HumuLIN R Injection 100U/ML,3203466,CDM,637,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-rOPINIRole Oral Extended Release Tab,3203469,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Potassium Chloride Oral Cap ER 10MEQ,3203470,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Cardizem CD Oral Capsule ER 120MG,3203471,CDM,637,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
NF-Combivent Inh Aer Pwd 103MCG-18MCG/1,3203472,CDM,637,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3203473,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act,3203474,CDM,250,RC,,,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
NF-Senokot S Oral Tablet 50MG-8.6MG,3203475,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Azor Oral Tablet 5MG-20MG,3203476,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-FLORANEX GRANULES ORAL GRANULE 5MG,3203477,CDM,250,RC,,,outpatient,,,7.52,5.64,,6.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.03,6.02,
NF-THERA-M W/MINERALS TABLET,3203478,CDM,250,RC,,,outpatient,,,0.23,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-Bacmin Oral Tablet,3203479,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-VELCADE INJ POWDER FOR SOLUTION 3.5MG,3203482,CDM,250,RC,,,outpatient,,,7117.32,5337.99,,5693.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2864.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3558.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3558.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3558.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3558.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3914.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5693.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5337.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5337.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5337.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5337.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2864.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2864.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5693.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5337.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5693.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5693.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2864.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5693.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5693.86,
NF-Aricept Tablet 5MG,3203483,CDM,637,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Metoprolol Tartrate Tablet 25MG,3203484,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Arimidex Tablet 1MG,3203485,CDM,637,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-HARVONI ORAL TABLET 90MG-400MG,3203486,CDM,250,RC,,,outpatient,,,4995,3746.25,,3996,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2009.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2497.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2497.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2497.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2497.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2747.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2009.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2009.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2009.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2009.99,3996,
NF-TORSEMIDE ORAL TABLET 20MG,3203487,CDM,250,RC,,,outpatient,,,3.04,2.28,,2.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.22,2.43,
NF-TWOCAL HN LIQUID,3203488,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-CEFPROZIL ORAL TABLET 500MG,3203490,CDM,250,RC,,,outpatient,,,33.46,25.1,,26.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.46,26.77,
NF-DIVALPROEX SODIUM CAP DR 125MG,3203491,CDM,250,RC,,,outpatient,,,6.7,5.03,,5.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.7,5.36,
NF-MELATONIN CAPSULE 5MG,3203492,CDM,250,RC,,,outpatient,,,0.56,0.42,,0.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.23,0.45,
NF-CLONIDINE HCL ORAL TAB ER 0.1MG,3203493,CDM,250,RC,,,outpatient,,,16.65,12.49,,13.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.7,13.32,
NF-GUANFACINE HCL TAB 2MG,3203494,CDM,250,RC,,,outpatient,,,2.07,1.55,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.83,1.66,
NF-MORPHINE SULFATE ORAL SOLUTION 20MG/1,3203495,CDM,250,RC,,,outpatient,,,1.46,1.1,,1.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.59,1.17,
NF-Co-Q-10 Oral Liquid Capsule 200MG,3203496,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Breo Ellipta Inhalation Powder,3203500,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Fiorinal Capsule,3203502,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Xarelto Oral Tablet 20MG,3203503,CDM,250,RC,,,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,42.4,
NF-BIOTIN ORAL TABLET 1000MCG,3203504,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-CHONDROITIN SULFATE-GLUCOSAMINE HCL-S,3203505,CDM,250,RC,,,outpatient,,,0.64,0.48,,0.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.26,0.51,
NF-RED YEAST RICE EXTRACT POWDER,3203506,CDM,250,RC,,,outpatient,,,3.11,2.33,,2.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.25,2.49,
NF-Myrbetriq Oral Tablet 25MG,3203507,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Amitiza Oral Liquid Filled Capsule 8M,3203508,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-EVAMIST TD SPRAY 1.53MG/1ACT,3203510,CDM,250,RC,,,outpatient,,,48.68,36.51,,38.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.59,38.94,
NF-Fiorinal Capsule,3203511,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Xarelto Oral Tablet 20MG,3203512,CDM,250,RC,,,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,42.4,
NF-Calcitriol Capsule 0.25MCG,3203514,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Reyataz Oral Capsule 300MG,3203515,CDM,637,RC,,,outpatient,,,202,151.5,,161.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,81.28,161.6,
NF-Truvada Oral Tablet 200MG-300MG,3203516,CDM,637,RC,,,outpatient,,,217,162.75,,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.32,173.6,
NF-BUDESONIDE CAP DR 3MG,3203517,CDM,250,RC,,,outpatient,,,60.91,45.68,,48.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.51,48.73,
NF-REMODULIN INJECTION SOLUTION 5MG/1ML,3203518,CDM,250,RC,,,outpatient,,,1363.45,1022.59,,1090.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,548.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,681.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,681.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,681.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,681.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,749.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1090.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,548.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,548.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1090.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1022.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1090.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1090.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,548.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1090.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,548.65,1090.76,
GLYDO TOPICAL APPLICATION GEL/JELLY 2%,3203520,CDM,250,RC,,,outpatient,,,6.04,4.53,,4.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.43,4.83,
NF-Xopenex HFA Inh/Neb Aer Pwd 0.045MG/1,3203521,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-CHLORTHALIDONE ORAL TABLET 25MG,3203523,CDM,250,RC,,,outpatient,,,4.47,3.35,,3.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.8,3.58,
NF-Prevacid Oral Cap DR 30MG,3203524,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Artificial Tears Ophth Solution,3203525,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Mirapex Tablet 0.25MG,3203526,CDM,637,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-hydrALAZINE HCl Oral Tablet 50MG,3203527,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-HumuLIN R Injection 100U/ML,3203529,CDM,637,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-ESOMEPRAZOLE MAGNESIUM CAP DR 40MG,3203531,CDM,250,RC,,,outpatient,,,38.89,29.17,,31.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.65,31.11,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3203532,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
LUGOL'S SOLUTION,3203533,CDM,250,RC,,,outpatient,,,5.58,4.19,,4.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.25,4.46,
NF-ADDERALL XR CAP ER 20MG,3203535,CDM,250,RC,,,outpatient,,,35.86,26.9,,28.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.43,28.69,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3203537,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Ocuvel Oral Capsule,3203539,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Nitro-Dur Transderm Patch ER 0.8MG/1H,3203540,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-AMLODIPINE & BENAZEPRIL HCL 10MG-20MG,3203542,CDM,250,RC,,,outpatient,,,12.29,9.22,,9.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.95,9.83,
NF-rivastigmine TD Patch ER 13.3MG/24HR,3203543,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-GASTROGRAFIN SOLN 66%-10%,3203544,CDM,250,RC,,,outpatient,,,1.41,1.06,,1.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.57,1.13,
NF-Omeprazole Oral Tab DR 20MG,3203545,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-diltiaZEM Oral Cap ER 120MG,3203546,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-RALOXIFENE HCL ORAL TABLET 60MG,3203547,CDM,250,RC,,,outpatient,,,26.37,19.78,,21.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.61,21.1,
NF-Namenda XR Oral Capsule ER 7MG,3203549,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-GRALISE ORAL TABLET 600MG,3203550,CDM,250,RC,,,outpatient,,,26.39,19.79,,21.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.62,21.11,
NF-NAMENDA XR CAP ER 28MG,3203552,CDM,250,RC,,,outpatient,,,52.38,39.29,,41.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.08,41.9,
NF-Prazosin HCl Capsule 1MG,3203553,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-SODIUM CHLORIDE HYPERTONICITY SOLN 5%,3203554,CDM,250,RC,,,outpatient,,,2.7,2.03,,2.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.09,2.16,
NF-SUCCINYLCHOLINE CHL INJ SOLN 20MG/1ML,3203555,CDM,250,RC,,,outpatient,,,10.15,7.61,,8.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.08,8.12,
NF-ETOMIDATE INJECTION 2MG/ML,3203556,CDM,250,RC,,,outpatient,,,4.91,3.68,,3.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.98,3.93,
NF-VECURONIUM BROM NOVAPLUS IV PWD FOR S,3203557,CDM,250,RC,,,outpatient,,,22.73,17.05,,18.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.15,18.18,
CLOMIPHENE CITRATE TABLET 50MG,3203558,CDM,637,RC,,,outpatient,,,25.6,19.2,,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.3,20.48,
NF-IVERMECTIN ORAL TABLET 3MG,3203559,CDM,250,RC,,,outpatient,,,18.39,13.79,,14.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.4,14.71,
NF-MATZIM LA ORAL TAB ER 180MG,3203562,CDM,250,RC,,,outpatient,,,11.01,8.26,,8.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.81,
DESONIDE TOPICAL APPLICATION CREAM 0.05%,3203563,CDM,637,RC,,,outpatient,,,75.85,56.89,,60.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.52,60.68,
ECONAZOLE NITRATE TOPICAL CREAM 1% 15 GM,3203564,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Depakote Delayed-Release Tablet 125MG,3203565,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Megace ES Oral Suspension 625MG/5ML,3203566,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Dyphylline Powder,3203568,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-ALPRAZOLAM DISINTEGRATING TAB 1MG,3203570,CDM,250,RC,,,outpatient,,,9.33,7,,7.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.75,7.46,
NF-LORCET HD ORAL TABLET 325MG-10MG,3203571,CDM,250,RC,,,outpatient,,,10.2,7.65,,8.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.1,8.16,
NF-Namenda XR Oral Capsule ER 7MG,3203575,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-CARBIDOPA AND LEVODOPA TAB ER 50-200M,3203580,CDM,250,RC,,,outpatient,,,7.03,5.27,,5.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.83,5.62,
NF-ENTACAPONE ORAL TABLET 200MG,3203581,CDM,250,RC,,,outpatient,,,14.63,10.97,,11.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.89,11.7,
NF-OMEPRAZOLE CAP DR 20MG,3203582,CDM,250,RC,,,outpatient,,,18.03,13.52,,14.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.26,14.42,
NF-BUSPIRONE HCL ORAL TABLET 7.5MG,3203583,CDM,250,RC,,,outpatient,,,4.04,3.03,,3.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.63,3.23,
NF-Breo Ellipta Inhalation Powder,3203589,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Good Neighbor Pharmacy Co Q10 Cap 100,3203590,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-DEXAMETHASONE SOD OPHTH SOLUTION 0.1%,3203591,CDM,250,RC,,,outpatient,,,15.61,11.71,,12.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.28,12.49,
NF-Benicar Oral Tablet 20MG,3203593,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Allegra-D 24 Hour Tablet 180MG-240MG,3203595,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Estroven Energy Oral Tablet,3203596,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NM PH TC99M PYROPHOSPHATE PER MCI,4400043,CDM,343,RC,A9538,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Linzess Oral Capsule 145MCG,3203598,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Nuedexta Oral Capsule 20MG-10MG,3203599,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Omeprazole Oral Tab DR 20MG,3203600,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-IMPACT PEPTIDE 1.5 CAL ORAL SOLUTION,3203601,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-Namenda XR Oral Capsule ER 7MG,3203602,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
PR NM BRAIN-STATIC,4410009,CDM,972,RC,7860526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-Invokana Oral Tablet 300MG,3203604,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Sprintec Tablet,3203605,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Tracleer Tablet 125MG,3203608,CDM,250,RC,,,outpatient,,,684,513,,547.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,376.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,275.24,547.2,
NF-Bactroban Ointment 2%,3203610,CDM,250,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
NF-Naproxen Oral Tablet 220MG,3203611,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-LUPRON DEPOT IM 6 MONTH PWD FOR SUSP,3203612,CDM,250,RC,,,outpatient,,,33238.32,24928.74,,26590.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13375.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16619.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16619.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16619.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16619.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18281.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26590.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24928.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24928.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24928.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24928.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13375.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13375.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26590.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24928.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26590.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26590.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13375.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,26590.66,
NF-Protonix Oral Granules 40MG,3203613,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Provigil Oral Tablet 200MG,3203614,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act,3203616,CDM,250,RC,,,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
NYSTATIN/TRIAMCINOLONE CRM 30GM,3203617,CDM,637,RC,,,outpatient,,,19.67,14.75,,15.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.92,15.74,
NF-Arimidex Tablet 1MG,3203618,CDM,250,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-CYANOCOBALAMIN CRYSTAL,3203623,CDM,250,RC,,,outpatient,,,1718.28,1288.71,,1374.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,691.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,859.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,859.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,859.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,859.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,945.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,691.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1374.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1288.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,691.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1374.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,691.44,1374.62,
NF-Depakote Sprinkles Capsule 125MG,3203624,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Nuedexta Oral Capsule 20MG-10MG,3203625,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-PENTAZOCINE AND NALOXONE HCL ORAL TAB,3203626,CDM,250,RC,,,outpatient,,,9.53,7.15,,7.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,7.62,
NF-Promethazine HCl Tablet 25MG,3203627,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CEFDINIR ORAL PWD FOR SUSP 250MG/5ML,3203628,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-BISOPROLOL FUMARATE ORAL TABLET 10MG,3203629,CDM,250,RC,,,outpatient,,,8.34,6.26,,6.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.36,6.67,
NF-CARAFATE TABLET 1GM,3203630,CDM,250,RC,,,outpatient,,,4.24,3.18,,3.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.71,3.39,
NF-TRACLEER ORAL TABLET 125MG,3203633,CDM,250,RC,,,outpatient,,,684.43,513.32,,547.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,376.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,275.41,547.54,
NF-ASTAGRAF XL CAP ER 0.5MG,3203634,CDM,250,RC,,,outpatient,,,8.8,6.6,,7.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.54,7.04,
NF-MYFORTIC ENTERIC-COATED TABLET 360MG,3203635,CDM,250,RC,,,outpatient,,,42.33,31.75,,33.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.03,33.86,
NF-MYRBETRIQ ORAL TABLET 50MG,3203636,CDM,250,RC,,,outpatient,,,43.92,32.94,,35.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.67,35.14,
PR NM LIVER/SPLEEN,4410015,CDM,972,RC,7821526,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-Proventil HFA Inhaler 0.09MG/Inh,3203638,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-LINEZOLID ORAL TABLET 600MG,3203639,CDM,250,RC,,,outpatient,,,679.58,509.69,,543.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,339.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,339.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,339.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,339.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,373.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,273.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,273.46,543.66,
NF-Macrobid Capsule 100MG,3203640,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Hydrocortisone Oral Tablet 10MG,3203642,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Oral Tablet 10MG,3203643,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Ketotifen Fumarate Ophth Solution 0.0,3203644,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Zaditor Ophth Solution 0.025%,3203645,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-CRANBERRY CONCENTRATE CAPSULE,3203646,CDM,250,RC,,,outpatient,,,0.42,0.32,,0.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.17,0.34,
NF-Sprintec Tablet,3203647,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3203649,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-ABREVA TOPICAL CREAM 10%,3203651,CDM,250,RC,,,outpatient,,,32.71,24.53,,26.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.16,26.17,
NF-LEVOCETIRIZINE DIHCL ORAL TABLET 5MG,3203652,CDM,250,RC,,,outpatient,,,11.38,8.54,,9.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.58,9.1,
NF-LOMEDIA 24 FE 1/20 TAB 20MCG-1MG;75MG,3203653,CDM,250,RC,,,outpatient,,,11.83,8.87,,9.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.76,9.46,
NF-KEPPRA ORAL TABLET 250MG,3203654,CDM,250,RC,,,outpatient,,,8.48,6.36,,6.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.41,6.78,
NF-JANUMET XR ORAL TAB ER 1000MG-50MG,3203655,CDM,250,RC,,,outpatient,,,26.89,20.17,,21.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.82,21.51,
NF-VITAMIN B COMPLEX CAPSULE,3203656,CDM,250,RC,,,outpatient,,,0.32,0.24,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-CALCI-CHEW ORAL TABLET 1250MG,3203657,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-QVAR Inh/Neb Aerosol Liquid 0.08MG/1A,3203659,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-ADDERALL XR CAP ER 10MG,3203660,CDM,250,RC,,,outpatient,,,21.42,16.07,,17.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.62,17.14,
NF-Zofran Odt Dissolve Tablet 8MG,3203661,CDM,250,RC,,,outpatient,,,162,121.5,,129.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.19,129.6,
NF-LaMICtal Tablet 200MG,3203663,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-TEGretol Oral Chewable Tablet 100MG,3203664,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Prevacid Oral Cap DR 30MG,3203667,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Artificial Tears Ophth Solution,3203668,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-hydrALAZINE HCl Oral Tablet 50MG,3203669,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-HumuLIN R Injection 100U/ML,3203670,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Femara Tablet 2.5MG,3203673,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-EFFEXOR-XR CAPSULE 150MG,3203674,CDM,250,RC,,,outpatient,,,40.97,30.73,,32.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.49,32.78,
NF-DICLOFENAC SODIUM CRM 3%,3203675,CDM,250,RC,,,outpatient,,,11.4,8.55,,9.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.59,9.12,
NF-HYDRALAZINE HCL ORAL TAB 50MG,3203676,CDM,250,RC,,,outpatient,,,4.22,3.17,,3.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.7,3.38,
NF-PROAIR RESPICLICK INH POWDER 117MCG/1,3203679,CDM,250,RC,,,outpatient,,,222.07,166.55,,177.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,89.36,177.66,
NF-ALL 100 SUPER B COMPLEX TABLET,3203680,CDM,250,RC,,,outpatient,,,0.45,0.34,,0.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.18,0.36,
NF-CRANBERRY CAPSULE 400MG,3203681,CDM,250,RC,,,outpatient,,,0.51,0.38,,0.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.41,
NF-Trintellix Oral Tablet 20MG,3203683,CDM,637,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Trintellix Oral Tablet 20MG,3203684,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
BRIDION SOLUTION 500MG/5ML,3203685,CDM,250,RC,,,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,182.4,
NF-PENTOXIFYLLINE ORAL TAB ER 400MG,3203686,CDM,250,RC,,,outpatient,,,3.19,2.39,,2.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.28,2.55,
NF-NATURE'S BLEND APPLE CIDER VINEGAR 60,3203687,CDM,250,RC,,,outpatient,,,0.17,0.13,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-Coenzyme Q-10 Liq Cap 200MG,3203689,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-THEOPHYLLINE 24 HR TAB ER 400MG,3203692,CDM,250,RC,,,outpatient,,,5.02,3.77,,4.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.02,4.02,
THEOPHYLLINE TABLET ER 400MG,3203693,CDM,637,RC,,,outpatient,,,5.02,3.77,,4.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.02,4.02,
NF-Potassium Chloride Oral Cap ER 10MEQ,3203694,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Lisinopril Tablet 2.5mg,3203695,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-PINDOLOL ORAL TABLET 5MG,3203696,CDM,250,RC,,,outpatient,,,4.07,3.05,,3.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.64,3.26,
NF-NovoLIN N (NPH) SubQ Susp 100U/1ML,3203697,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-valsartan Oral Tablet 320MG,3203698,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3203699,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-NovoLIN R Injection 100U/ML,3203700,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-CALCIUM 600 PLUS VITAMIN D-3 & MINERA,3203701,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-Namenda XROral Capsule ER 28MG,3203702,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Adderall Oral Tablet,3203704,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-rivastigmine TD Patch ER 13.3MG/24HR,3203705,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
PR NM PAROTID/SALIVARY,4410025,CDM,972,RC,7823026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-Methotrexate Oral Tablet 2.5MG,3203707,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-DITROPAN XL EXTENDED-RELEASE TABLET 5,3203708,CDM,250,RC,,,outpatient,,,15.27,11.45,,12.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.14,12.22,
NF-LOTREL CAP 10MG-40MG,3203709,CDM,250,RC,,,outpatient,,,46.97,35.23,,37.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.9,37.58,
NF-Proair HFA Inh Susp 0.09MG/1Act,3203710,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Glimepiride Oral Tablet 1MG,3203711,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-ENTRESTO ORAL TABLET 49MG-51MG,3203712,CDM,250,RC,,,outpatient,,,29.94,22.46,,23.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.05,23.95,
NF-ROXICODONE ORAL TABLET 30MG,3203713,CDM,250,RC,,,outpatient,,,6.27,4.7,,5.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.52,5.02,
NF-Hydrocortisone Oral Tablet 10MG,3203714,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Oral Tablet 10MG,3203715,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Ketotifen Fumarate Ophth Solution 0.0,3203716,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Zaditor Ophth Solution 0.025%,3203717,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-TRULICITY SUBQ SOLN 0.75MG/0.5ML,3203718,CDM,250,RC,,,outpatient,,,1389.72,1042.29,,1111.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,559.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,694.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,694.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,694.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,694.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,764.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,559.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,559.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1042.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,559.22,1111.78,
NF-DITROPAN XL TAB ER 15MG,3203719,CDM,250,RC,,,outpatient,,,16.8,12.6,,13.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.76,13.44,
NF-CORTROSYN INJ PWD FOR SOLN 0.25MG,3203720,CDM,250,RC,,,outpatient,,,473.22,354.92,,378.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,236.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,190.42,378.58,
NF-ZOCOR ORAL TABLET 80MG,3203721,CDM,250,RC,,,outpatient,,,33.79,25.34,,27.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.6,27.03,
CROMOLYN SODIUM OPHTH SOLUTION 4% 10 ml,3203722,CDM,637,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-GENTEAL OPHTHALMIC SOLUTION 0.2%,3203723,CDM,250,RC,,,outpatient,,,1.67,1.25,,1.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.67,1.34,
NF-Hydrocortisone Oral Tablet 10MG,3203724,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Oral Tablet 10MG,3203725,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Ketotifen Fumarate Ophth Solution 0.0,3203726,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Zaditor Ophth Solution 0.025%,3203727,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-VIBERZI ORAL TABLET 100MG,3203734,CDM,250,RC,,,outpatient,,,71.04,53.28,,56.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.59,56.83,
NF-KlonoPIN Tablet 1MG,3203736,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3203738,CDM,250,RC,,,outpatient,,,1389,1041.75,,1111.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,558.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,694.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,694.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,694.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,694.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,763.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1041.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,558.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,558.93,1111.2,
NF-Hydrocortisone Oral Tablet 10MG,3203739,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Oral Tablet 10MG,3203740,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Restoril Capsule 7.5MG,3203741,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Fenofibrate Oral Tablet 48MG,3203743,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
TRIMETHOPRIM TABLET 100MG,3203746,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-VIT B COMPLEX AND IRON-VIT B COMPLEX,3203747,CDM,250,RC,,,outpatient,,,9.52,7.14,,7.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,7.62,
"NF-OMEGA-3 ORAL CAPSULE, LIQUID FILLED",3203748,CDM,250,RC,,,outpatient,,,0.4,0.3,,0.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.32,
NF-I-VITE LUTEIN ORAL TABLET,3203749,CDM,250,RC,,,outpatient,,,0.29,0.22,,0.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.23,
NF-CO Q-10 LIQUID CAPSULE 100MG,3203750,CDM,250,RC,,,outpatient,,,1.7,1.28,,1.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.36,
NF-Metoprolol Tartrate Tablet 50MG,3203752,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Mirtazapine Tablet 15MG,3203753,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
LANSOPRAZOLE ORAL CAPSULE DR 30MG,3203755,CDM,637,RC,,,outpatient,,,6.47,4.85,,5.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.6,5.18,
VALSARTAN/HCTZ ORAL TABLET 160MG-12.5MG,3203756,CDM,637,RC,,,outpatient,,,4.23,3.17,,3.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.7,3.38,
NF-REPREXAIN ORAL TABLET 10MG-200MG,3203757,CDM,250,RC,,,outpatient,,,16.83,12.62,,13.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,13.46,
NF-PROMETHAZINE HCL ORAL TABLET 50MG,3203758,CDM,250,RC,,,outpatient,,,2.87,2.15,,2.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.15,2.3,
NF-VITAMIN D ORAL CAPSULE 5000IU,3203760,CDM,250,RC,,,outpatient,,,0.43,0.32,,0.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.17,0.34,
NF-B-COMPLEET ORAL TABLET,3203761,CDM,250,RC,,,outpatient,,,0.26,0.2,,0.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.21,
NF-BRILINTA ORAL TABLET 60MG,3203762,CDM,250,RC,,,outpatient,,,24.64,18.48,,19.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.92,19.71,
NF-DIAZEPAM ORAL TABLET  10MG,3203763,CDM,250,RC,,,outpatient,,,1.22,0.92,,0.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.98,
NF-DILAUDID ORAL TABLET 4MG,3203764,CDM,250,RC,,,outpatient,,,8.05,6.04,,6.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.24,6.44,
NF-PRAVASTATIN SODIUM ORAL TABLET 80MG,3203765,CDM,250,RC,,,outpatient,,,17.74,13.31,,14.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.14,14.19,
NF-Singulair Tablet 10MG,3203766,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
PR NM RENAL VASCULAR FLOW,4410052,CDM,972,RC,7870126,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-Nitroglycerin Sublingual Tablet 0.4MG,3203769,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Flomax Oral Capsule 0.4MG,3203770,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-CELLCEPT TAB 500MG,3203771,CDM,250,RC,,,outpatient,,,75.36,56.52,,60.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.32,60.29,
NF-FERREX 150 CAPSULE 150MG,3203772,CDM,250,RC,,,outpatient,,,1.02,0.77,,0.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.41,0.82,
NF-PERI-COLACE TABLET 50MG-8.6MG,3203773,CDM,250,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-Tamoxifen Citrate Oral Tablet 20MG,3203774,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Omeprazole Oral Tab DR 20MG,3203775,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-hydroCHLOROthiazide Capsule 12.5MG,3203777,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Cardizem LA Oral Tab ER 180MG,3203778,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Proair HFA Inh Susp 0.09MG/1Act,3203779,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Tamoxifen Citrate Tab 20MG,3203780,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Tamiflu Powder For Suspension 6MG/1ML,3203781,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-STIOLTO RESPIMAT INH 2.5-2.5MCG/1ACT,3203782,CDM,250,RC,,,outpatient,,,378.44,283.83,,302.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.28,302.75,
NF-NexIUM Capsule 40MG,3203783,CDM,250,RC,,,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,42.4,
NF-FLUoxetine Hydrochloride Tablet 10MG,3203785,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-GenTeal Ophthalmic Solution 0.2%,3203786,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Amitiza Oral Liquid Filled Capsule 8M,3203787,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Pravastatin Sodium Oral Tablet 10MG,3203788,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Nitroglycerin Sublingual Tablet 0.4MG,3203790,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
PFIZERPEN POWDER FOR INJ 5MILLIONU,3203791,CDM,250,RC,,,outpatient,,,56.2,42.15,,44.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.61,44.96,
NF-Nitroglycerin Sublingual Tablet 0.4MG,3203792,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Potassium Iodate Powder,3203793,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LINEZOLID ORAL TABLET 600MG,3203794,CDM,637,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Advair Diskus 250/50 Disk,3203795,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3203796,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Zofran Odt Dissolve Tablet 4MG,3203797,CDM,250,RC,,,outpatient,,,97,72.75,,77.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.03,77.6,
NF-OSPHENA ORAL TABLET 60MG,3203798,CDM,250,RC,,,outpatient,,,24.67,18.5,,19.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.93,19.74,
NF-Namenda XROral Capsule ER 28MG,3203799,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Zanaflex Oral Tablet 2MG,3203800,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-hydrALAZINE HCl Oral Tablet 50MG,3203801,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-AUGMENTIN XR ORAL TABLET ER 1000MG,3203802,CDM,250,RC,,,outpatient,,,18.64,13.98,,14.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.5,14.91,
NF-APAP/Codeine Tablet 300 Mg-15 Mg,3203803,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Hydrocortisone Oral Tablet 10MG,3203805,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Oral Tablet 10MG,3203806,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
CALCIUM ACETATE TABLET 667MG,3203808,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-MISOPROSTOL ORAL TABLET 200MCG,3203809,CDM,250,RC,,,outpatient,,,4.44,3.33,,3.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.79,3.55,
NF-LOFIBRA ORAL TABLET 54MG,3203810,CDM,250,RC,,,outpatient,,,6.86,5.15,,5.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.76,5.49,
NF-Apidra Solostar Inj Soln 100U/1ML,3203812,CDM,250,RC,,,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,116,
NF-BISOPROLOL FM ORAL TABLET 5MG,3203813,CDM,250,RC,,,outpatient,,,5.42,4.07,,4.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.18,4.34,
NF-NEXIUM 24HR CAP DR 20MG,3203814,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-WELLBUTRIN ORAL TABLET 100MG,3203815,CDM,250,RC,,,outpatient,,,6.88,5.16,,5.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,5.5,
NF-Atripla Oral Tablet 600MG-200MG-300MG,3203817,CDM,250,RC,,,outpatient,,,362,271.5,,289.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.67,289.6,
NF-Ciprofloxacin Ophthalmic Solution 0.3,3203818,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-SINEMET CR TAB ER 50MG-200MG,3203819,CDM,250,RC,,,outpatient,,,9.31,6.98,,7.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.75,7.45,
NF-Amitiza Oral Liquid Filled Capsule 8M,3203820,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3203821,CDM,250,RC,,,outpatient,,,378,283.5,,302.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.11,302.4,
NF-Anoro Ellipta Inhalation Powder,3203822,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Hydrocortisone Oral Tablet 10MG,3203823,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Oral Tablet 10MG,3203824,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-RESTORIL CAP 7.5MG,3203825,CDM,250,RC,,,outpatient,,,87.33,65.5,,69.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.14,69.86,
NF-Kombiglyze XR Oral Extended Release T,3203827,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Vascepa Oral Liquid Filled Cap 1GM,3203828,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-ROZEREM ORAL TABLET 8MG,3203829,CDM,250,RC,,,outpatient,,,49.75,37.31,,39.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.02,39.8,
NF-hydrALAZINE HCl Oral Tablet 25,3203830,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-metFORMIN HCl Tablet 500MG,3203831,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-cloNIDine HCl Oral Tab ER 0.1MG,3203832,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Percocet Oral Tablet 7.5MG-325MG,3203833,CDM,250,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
NF-SAVELLA ORAL TABLET 50MG,3203834,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
"NF-VITAMIN A CAPSULE 10,000IU",3203835,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-Arthrotec 75 Oral Tablet 75MG-200MCG,3203836,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Dutoprol Oral Tablet ER 12.5MG-50MG,3203837,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-RESTASIS MULTIDOSE OPHTH EMUL 0.05%,3203838,CDM,250,RC,,,outpatient,,,344.49,258.37,,275.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,138.62,275.59,
NF-AXIRON SOLN 30MG/1.5ML,3203839,CDM,250,RC,,,outpatient,,,28.29,21.22,,22.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.38,22.63,
NF-TRIFLUOPERAZINE HCL ORAL TABLET 2MG,3203840,CDM,250,RC,,,outpatient,,,4.77,3.58,,3.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.92,3.82,
NF-METHENAMINE HIPPURATE 1GM TABLET,3203844,CDM,637,RC,,,outpatient,,,7.74,5.81,,6.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.11,6.19,
NF-THEOPHYLLINE 12 HR TAB ER 100MG,3203846,CDM,250,RC,,,outpatient,,,2.03,1.52,,1.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.62,
NF-THEOPHYLLINE 12 HR TAB ER 200MG,3203847,CDM,250,RC,,,outpatient,,,2.06,1.55,,1.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.83,1.65,
NF-DALIRESP ORAL TABLET 500MCG,3203848,CDM,250,RC,,,outpatient,,,38.17,28.63,,30.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.36,30.54,
NF-Lovastatin Tablet 10MG,3203849,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-GLUCOSAMINE CHONDROITIN 1500 COM CAPS,3203851,CDM,250,RC,,,outpatient,,,1.06,0.8,,0.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.43,0.85,
NF-VITAMIN E CAPSULE 1000IU,3203855,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-Nuedexta Oral Capsule 20MG-10MG,3203857,CDM,250,RC,,,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,44,
NF-Trintellix Oral Tablet 20MG,3203858,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
CHANTIX ORAL TABLET 0.5MG-1MG,3203860,CDM,637,RC,,,outpatient,,,332.65,249.49,,266.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.86,266.12,
NF-PROGRAF CAP 0.5MG,3203861,CDM,250,RC,,,outpatient,,,7.21,5.41,,5.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.9,5.77,
NF-ARMOUR THYROID TABLET 300MG,3203862,CDM,250,RC,,,outpatient,,,1.53,1.15,,1.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.62,1.22,
NF-ARIPiprazole Oral Tablet 15MG,3203863,CDM,250,RC,,,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.48,94.4,
NF-Tradjenta Oral Tablet 5MG,3203864,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-SEROquel XR Oral Tab ER 200MG,3203865,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Namenda XROral Capsule ER 28MG,3203866,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-MODAFINIL ORAL TABLET 200MG,3203867,CDM,250,RC,,,outpatient,,,123.33,92.5,,98.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.63,98.66,
NF-ROPINIROLE HCL TAB 4MG,3203868,CDM,250,RC,,,outpatient,,,10.43,7.82,,8.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.2,8.34,
NF-Plavix Oral Tablet 300MG,3203869,CDM,250,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
NF-Plavix Oral Tablet 300MG,3203870,CDM,250,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
NF-METHYLPHENIDATE HCL ORAL TAB ER 36MG,3203872,CDM,250,RC,,,outpatient,,,44.05,33.04,,35.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.73,35.24,
TELMISARTAN ORAL TABLET 40MG,3203873,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
OMEPRAZOLE DELAYED-RELEASE CAPSULE 40MG,3203874,CDM,637,RC,,,outpatient,,,8.15,6.11,,6.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.28,6.52,
NF-VIBERZI ORAL TABLET 75MG,3203876,CDM,250,RC,,,outpatient,,,77.43,58.07,,61.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.16,61.94,
NF-LAMOTRIGINE ORAL CHEWABLE TABLET 25MG,3203877,CDM,250,RC,,,outpatient,,,11.83,8.87,,9.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.76,9.46,
NF-Methenamine Hippurate 1GM Tablet,3203878,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-NexIUM Capsule 20MG,3203879,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Carafate Tablet 1GM,3203880,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
OMEPRAZOLE DELAYED-RELEASE CAPSULE 20MG,3203882,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
PR NM RENAL-STATIC ONLY,4410053,CDM,972,RC,7870026,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-ORTHO TRI-CYCLEN LO TAB 0.025MG-0.18M,3203884,CDM,250,RC,,,outpatient,,,13.92,10.44,,11.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.6,11.14,
NF-OMEGA-3 LIQUID FILLED CAPSULE 1000MG,3203886,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-TRIGLIDE ORAL TABLET 160MG,3203887,CDM,250,RC,,,outpatient,,,42.24,31.68,,33.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17,33.79,
NF-COQ10/VITAMIN E LIQ CAP 100MG-10IU,3203888,CDM,250,RC,,,outpatient,,,0.72,0.54,,0.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.29,0.58,
MONSEL'S TOPICAL SOLUTION 0.22GM/1ML,3203890,CDM,250,RC,,,outpatient,,,12.75,9.56,,10.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.13,10.2,
NF-Apidra Injection Solution 100U/1ML,3203891,CDM,250,RC,,,outpatient,,,113,84.75,,90.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.47,90.4,
NF-Diclofenac Sodium Topical Solution 1.,3203892,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-DEXTROAMPHETAMINE SULFATE CAP ER 10MG,3203893,CDM,250,RC,,,outpatient,,,18.72,14.04,,14.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.53,14.98,
NF-PROTEINEX ORAL TABLET,3203895,CDM,250,RC,,,outpatient,,,0.77,0.58,,0.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.31,0.62,
CLINDAMYCIN 600MG/NSS 50 ML PM,3203896,CDM,250,RC,,,outpatient,,,49.5,37.13,,39.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.92,39.6,
NF-FLECTOR PATCH ER 1.3%,3203898,CDM,250,RC,,,outpatient,,,36.07,27.05,,28.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.51,28.86,
NF-Namenda XROral Capsule ER 28MG,3203902,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-ZALEPLON CAP 10MG,3203903,CDM,250,RC,,,outpatient,,,12.7,9.53,,10.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.11,10.16,
NF-UTI-STAT ORAL SOLUTION,3203905,CDM,250,RC,,,outpatient,,,0.13,0.1,,0.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.05,0.1,
NF-buPROPion Hydrochloride Tablet 100MG,3203907,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Rozerem Oral Tablet 8MG,3203908,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-AUGMENTIN ES-600 ORAL PWD FOR SUSP,3203909,CDM,250,RC,,,outpatient,,,3.01,2.26,,2.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.41,
NF-KlonoPIN Tablet 1MG,3203911,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Omeprazole Cap DR 40MG,3203912,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Bumetanide Tablet 2MG,3203913,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Truvada Oral Tablet 200MG-300MG,3203914,CDM,250,RC,,,outpatient,,,239,179.25,,191.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.17,191.2,
NF-DUREZOL OPHTH EMUL 0.05%,3203920,CDM,250,RC,,,outpatient,,,95.19,71.39,,76.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.3,76.15,
NF-PHAZYME CHEWABLE TABLET 125MG,3203921,CDM,250,RC,,,outpatient,,,0.73,0.55,,0.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.29,0.58,
NF-Geodon Capsule 60MG,3203922,CDM,250,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
NF-Macrobid Capsule 100MG,3203923,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-OXcarbazepine Oral Tablet 300MG,3203924,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Armour Thyroid Tablet 240MG,3203925,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Advair Diskus 250/50 Disk,3203926,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Levocetirizine Dihydrochloride Tab 5M,3203927,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-rOPINIRole Hydrochloride Tablet 4MG,3203929,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Modafinil Oral Tablet 200MG,3203930,CDM,250,RC,,,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.5,98.4,
NF-Wellbutrin SR 12 Hr Tab ER 150MG,3203931,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Crestor Tablet 40MG,3203932,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-QVAR Inh/Neb Aerosol Liquid 0.04MG/1A,3203933,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-ProAir RespiClick Inh Powder 117MCG/1,3203934,CDM,250,RC,,,outpatient,,,235,176.25,,188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.56,188,
NF-Trileptal Tablet 300MG,3203935,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-LYRICA CAP 300MG,3203936,CDM,250,RC,,,outpatient,,,27.94,20.96,,22.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.24,22.35,
NF-NEPHROCAPS LIQ CAP,3203937,CDM,250,RC,,,outpatient,,,23.66,17.75,,18.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.52,18.93,
FLAREX OPHTH SUSPENSION 0.1%,3203938,CDM,637,RC,,,outpatient,,,66.05,49.54,,52.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.58,52.84,
NF-TYLENOL ARTHRITIS ORAL TABLET ER 650M,3203944,CDM,250,RC,,,outpatient,,,0.72,0.54,,0.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.29,0.58,
NF-PROMETH W/ DEXTROMETHORPHAN HBR ORAL,3203945,CDM,250,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
NF-XYZAL ALLERGY 24HR ORAL TABLET 5MG,3203946,CDM,250,RC,,,outpatient,,,2.97,2.23,,2.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.2,2.38,
NF-Keppra Oral Tablet 1000MG,3203948,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Trintellix Oral Tablet 20MG,3203950,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Spironolactone Tablet 50MG,3203952,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Sucralfate Oral Tablet 1GM,3203953,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-TYLENOL W/CODEINE #4 TABLET 300MG-60M,3203954,CDM,250,RC,,,outpatient,,,8.33,6.25,,6.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.35,6.66,
NF-ISOSOURCE 1.5 CAL LIQUID,3203956,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
PRAMIPEXOLE ORAL TABLET 1MG,3203957,CDM,637,RC,,,outpatient,,,3.39,2.54,,2.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.36,2.71,
NF-Hydrocortisone Oral Tablet 10MG,3203958,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Oral Tablet 10MG,3203959,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-MYCOPHENOLATE MOFETIL ORAL TABLET 500,3203960,CDM,250,RC,,,outpatient,,,29.36,22.02,,23.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.81,23.49,
NF-Mycophenolate Mofetil Tablet 500MG,3203961,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Lovaza Oral Liquid Filled Capsule 1GM,3203962,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
TRI-LO-MARZIA TABLET,3203966,CDM,637,RC,,,outpatient,,,19.5,14.63,,15.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.85,15.6,
NF-CREON ORAL DELAYED RELEASE CAPSULE,3203967,CDM,250,RC,,,outpatient,,,12.16,9.12,,9.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.89,9.73,
NF-ESOMEPRAZOLE MAGNESIUM CAP DR 40MG,3203968,CDM,250,RC,,,outpatient,,,31.12,23.34,,24.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.52,24.9,
NF-CYPROHEPTADINE HCL ORAL SYRUP 2MG/5ML,3203969,CDM,250,RC,,,outpatient,,,0.48,0.36,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-XULANE TD PATCH ER 35MCG-150MCG/24HR,3203971,CDM,250,RC,,,outpatient,,,163.29,122.47,,130.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.71,130.63,
NF-Trintellix Oral Tablet 20MG,3203972,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3203973,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Naltrexone Oral Tablet 50MG,3203974,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Xulane TD Patch ER 35MCG-150MCG/24HR,3203975,CDM,250,RC,,,outpatient,,,163,122.25,,130.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.59,130.4,
NF-fluvoxaMINE Maleate Capsule ER 150MG,3203976,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-XYZAL ALLERGY 24HR ORAL TABLET 5MG,3203977,CDM,250,RC,,,outpatient,,,1.51,1.13,,1.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.61,1.21,
NF-BYDUREON PEN SUBQ PWD FOR SUSP ER 2MG,3203978,CDM,250,RC,,,outpatient,,,691.3,518.48,,553.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,380.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,278.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,278.18,553.04,
SODIUM CHLORIDE 0.9% 10 ML VIAL,3203979,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-AZILECT ORAL TABLET 1MG,3203983,CDM,250,RC,,,outpatient,,,102.77,77.08,,82.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.35,82.22,
NF-BYETTA SUBCUTANEOUS SOLUTION 250MCG/1,3203986,CDM,250,RC,,,outpatient,,,790.12,592.59,,632.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,317.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,395.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,434.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,632.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,632.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,317.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,632.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.94,632.1,
NF-PERIDEX ORAL SOLUTION 0.12%,3203988,CDM,250,RC,,,outpatient,,,0.69,0.52,,0.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.28,0.55,
ESTRADIOL TRANSDERMAL SYSTEM 0.0375/24,3203989,CDM,637,RC,,,outpatient,,,81.77,61.33,,65.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.9,65.42,
SODIUM CHLORIDE INJECTION SOLUTION 0.9%,3203990,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-INVOKAMET ORAL TABLET 150MG-500MG,3203991,CDM,250,RC,,,outpatient,,,31.57,23.68,,25.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.7,25.26,
NF-TEGRETOL XR ORAL TAB ER 200MG,3203992,CDM,250,RC,,,outpatient,,,4.37,3.28,,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.76,3.5,
NF-CYTOTEC ORAL TABLET 100MCG,3203993,CDM,250,RC,,,outpatient,,,12.44,9.33,,9.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.01,9.95,
NF-ZONTIVITY ORAL TABLET 2.08MG,3203994,CDM,250,RC,,,outpatient,,,42.73,32.05,,34.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.19,34.18,
NF-DICLOFEX DC TOPICAL KIT,3203995,CDM,250,RC,,,outpatient,,,61.09,45.82,,48.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.58,48.87,
NF-VITAMIN B6 ORAL TABLET 100MG,3203996,CDM,250,RC,,,outpatient,,,2.04,1.53,,1.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.82,1.63,
NF-Lasix Tablet 20MG,3203997,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Valsartan/HCTZ Oral Tablet 320MG-25MG,3203998,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Vitamin D Oral Tablet 5000IU,3203999,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-ULTRACET ORAL TABLET 37.5MG-325MG,3204003,CDM,250,RC,,,outpatient,,,10.13,7.6,,8.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.08,8.1,
NF-PROCTOSOL-HC TOPICAL CREAM 2.5%,3204004,CDM,250,RC,,,outpatient,,,3.26,2.45,,2.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.31,2.61,
ROPINIROLE HYDROCHLORIDE  TABLET 2MG,3204005,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-MYCOPHENOLATE MOFETIL ORAL TABLET 500,3204006,CDM,250,RC,,,outpatient,,,29.36,22.02,,23.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.81,23.49,
NF-ALBUTEROL INH/NEB SOLUTION 0.042%,3204007,CDM,250,RC,,,outpatient,,,5.65,4.24,,4.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.27,4.52,
NF-AZO URINARY PAIN RELIEF ORAL TABLET 9,3204008,CDM,250,RC,,,outpatient,,,8.47,6.35,,6.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.41,6.78,
FLORASTOR ORAL CAPSULE 250MG,3204009,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DEXTROSE INTRAVENOUS SOLUTION 25% 10ML,3204010,CDM,250,RC,,,outpatient,,,33.95,25.46,,27.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.66,27.16,
ONDANSETRON DISINTEGRATING TABLET 8MG,3204011,CDM,637,RC,,,outpatient,,,135.65,101.74,,108.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.59,108.52,
NF-AMOXICILLIN CHEW TAB 200MG,3204012,CDM,250,RC,,,outpatient,,,1.65,1.24,,1.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.66,1.32,
NF-BISOPROLOL-HYDROCHLOROTHIAZIDE TAB 10,3204013,CDM,250,RC,,,outpatient,,,5.9,4.43,,4.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,4.72,
NF-PRANDIN ORAL TABLET 1MG,3204014,CDM,250,RC,,,outpatient,,,27.78,20.84,,22.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.18,22.22,
CELECOXIB ORAL CAPSULE 100MG,3204015,CDM,637,RC,,,outpatient,,,1.1,0.83,,0.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.44,0.88,
NF-ZYPREXA ORAL TABLET 10MG,3204016,CDM,250,RC,,,outpatient,,,90.65,67.99,,72.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.48,72.52,
NF-ROPINIROLE HCL TAB 0.5MG,3204017,CDM,250,RC,,,outpatient,,,23.76,17.82,,19.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.56,19.01,
NF-LITHIUM CITRATE ORAL SOLUTION 8MEQ/5M,3204018,CDM,250,RC,,,outpatient,,,0.76,0.57,,0.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.31,0.61,
NF-NEURONTIN ORAL TABLET 800MG,3204019,CDM,250,RC,,,outpatient,,,13.1,9.83,,10.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.27,10.48,
NF-NEURONTIN ORAL TABLET 800MG,3204021,CDM,250,RC,,,outpatient,,,15.95,11.96,,12.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.42,12.76,
NF-LOVASTATIN ORAL TABLET 10MG,3204022,CDM,250,RC,,,outpatient,,,8.34,6.26,,6.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.36,6.67,
NF-BUTRANS TD PATCH ER 10MCG/1HR,3204024,CDM,250,RC,,,outpatient,,,408.19,306.14,,326.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,164.26,326.55,
NF-FE-20 ORAL CAPSULE 20MG,3204025,CDM,250,RC,,,outpatient,,,0.16,0.12,,0.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.13,
NF-FOLIVANE-F CAP,3204026,CDM,250,RC,,,outpatient,,,1.74,1.31,,1.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.7,1.39,
NF-ALEVE CAP 220MG,3204027,CDM,250,RC,,,outpatient,,,0.64,0.48,,0.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.26,0.51,
NF-HYDROCODONE-CHLORPHENIRAMINE MALEATE-,3204028,CDM,250,RC,,,outpatient,,,3.24,2.43,,2.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.3,2.59,
NF-JARDIANCE ORAL TABLET 10MG,3204029,CDM,250,RC,,,outpatient,,,63.72,47.79,,50.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.64,50.98,
NF-COSOPT PF OPHTH SOLN 2%-0.5%,3204031,CDM,250,RC,,,outpatient,,,6.33,4.75,,5.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.55,5.06,
NF-ALAWAY OPHTHALMIC SOLUTION 0.025%,3204032,CDM,250,RC,,,outpatient,,,3.83,2.87,,3.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.54,3.06,
NF-SIROLIMUS ORAL TABLET 1MG,3204033,CDM,250,RC,,,outpatient,,,63.08,47.31,,50.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.38,50.46,
NF-SODIUM BICARBONATE POWDER,3204034,CDM,250,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-PRO-STAT SUGAR FREE AWC ORAL LIQUID,3204035,CDM,250,RC,,,outpatient,,,0.25,0.19,,0.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.1,0.2,
NF-PYRIDOSTIGMINE BROMIDE ORAL TABLET 60,3204036,CDM,250,RC,,,outpatient,,,5.48,4.11,,4.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.38,
CLINDAMYCIN-BENZOYL PEROXIDE GEL 1%-5%,3204037,CDM,250,RC,,,outpatient,,,204.19,153.14,,163.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.17,163.35,
NF-FERATE TABLET 27MG,3204038,CDM,250,RC,,,outpatient,,,0.17,0.13,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-MAGNESIUM OXIDE POWDER,3204039,CDM,250,RC,,,outpatient,,,0.44,0.33,,0.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.18,0.35,
NF-MULTIVITAMINS TABLET,3204040,CDM,250,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-CARDIZEM ORAL TABLET 30MG,3204041,CDM,250,RC,,,outpatient,,,12.84,9.63,,10.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.17,10.27,
NF-DIFLUCAN TAB 200MG,3204042,CDM,250,RC,,,outpatient,,,78.92,59.19,,63.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.76,63.14,
NF-MUCUS RELIEF ORAL TABLET 400MG,3204043,CDM,250,RC,,,outpatient,,,0.53,0.4,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-PALIPERIDONE ORAL TABLET ER 3MG,3204044,CDM,250,RC,,,outpatient,,,112.95,84.71,,90.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.45,90.36,
NF-PALIPERIDONE ORAL TABLET ER 6MG,3204045,CDM,250,RC,,,outpatient,,,113.21,84.91,,90.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.56,90.57,
NF-PALIPERIDONE ORAL TABLET ER 3MG,3204046,CDM,250,RC,,,outpatient,,,112.95,84.71,,90.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.45,90.36,
NF-DENAVIR           CRE  1%,3204047,CDM,250,RC,,,outpatient,,,130.44,97.83,,104.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.49,104.35,
"NF-VITAMIN A CAPSULE 10,000IU",3204049,CDM,250,RC,,,outpatient,,,0.17,0.13,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-ATOMOXETINE ORAL CAPSULE 40MG,3204050,CDM,250,RC,,,outpatient,,,57.16,42.87,,45.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23,45.73,
NF-CLORAZEPATE DIPOTASSIUM ORAL TAB 3.75,3204051,CDM,250,RC,,,outpatient,,,1.98,1.49,,1.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.58,
NF-PRAMOXINE HYDROCHLORIDE FOAM 1%,3204052,CDM,250,RC,,,outpatient,,,2.29,1.72,,1.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.92,1.83,
NF-SENNA DOCUSATE TABLET 50MG,3204053,CDM,250,RC,,,outpatient,,,0.68,0.51,,0.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.27,0.54,
NF-UTI-STAT ORAL SOLUTION,3204054,CDM,250,RC,,,outpatient,,,0.15,0.11,,0.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.12,
NF-ARIPIPRAZOLE DISINTEGRATING TAB 10MG,3204055,CDM,250,RC,,,outpatient,,,141.08,105.81,,112.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.77,112.86,
NF-JADENU ORAL TABLET 360MG,3204057,CDM,250,RC,,,outpatient,,,631.84,473.88,,505.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,315.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,505.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,254.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,505.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,505.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,505.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,505.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,254.25,505.47,
NF-RIZATRIPTAN BENZOATE DISINTEGRATING T,3204058,CDM,250,RC,,,outpatient,,,162.37,121.78,,129.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.34,129.9,
OFLOXACIN OPHTHALMIC SOLUTION 0.3%,3204060,CDM,637,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
NF-ENTRESTO ORAL TABLET 49MG-51MG,3204062,CDM,250,RC,,,outpatient,,,32.04,24.03,,25.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.89,25.63,
OFLOXACIN OPHTHALMIC SOLUTION 0.3%,3204063,CDM,637,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
OFLOXACIN OPTH SOLU 0.3% 5ML,3204064,CDM,637,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-LORATADINE CHEW TAB 5MG,3204065,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-INCRUSE ELLIPTA INH PWD 62.5MCG/1ACT,3204066,CDM,250,RC,,,outpatient,,,43.56,32.67,,34.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.53,34.85,
NF-FENOFIBRIC ACID ORAL CAPSULE DR 135MG,3204067,CDM,250,RC,,,outpatient,,,22.18,16.64,,17.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.93,17.74,
BUPIVACAINE INJ. .25% 10 ML,3204068,CDM,250,RC,,,outpatient,,,1.25,0.94,,1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.5,1,
PR NM THYROID TC 99M UPTAKE AND IMAGING,4410062,CDM,972,RC,7801426,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-AZELASTINE HCL NASAL SPRAY 205.5MCG/1,3204070,CDM,250,RC,,,outpatient,,,17.17,12.88,,13.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.91,13.74,
NF-METOLAZONE ORAL TABLET 2.5MG,3204071,CDM,250,RC,,,outpatient,,,12.16,9.12,,9.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.89,9.73,
NF-ISOSORBIDE DINITRATE CAP ER 40MG,3204072,CDM,250,RC,,,outpatient,,,4.43,3.32,,3.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.78,3.54,
OT SELF CARE MGMT TRAINING 15 MIN,5100008,CDM,430,RC,97535GO,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-GLUCOSAMINE & CHONDR CAP 500MG-400MG,3204074,CDM,250,RC,,,outpatient,,,2.37,1.78,,1.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.9,
NF-OMEPRAZOLE CAP DR 40MG,3204075,CDM,250,RC,,,outpatient,,,1.21,0.91,,0.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.49,0.97,
NF-METHOTREXATE ORAL TABLET 2.5MG,3204078,CDM,250,RC,,,outpatient,,,19.72,14.79,,15.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.94,15.78,
OT THERAPEUTIC ACTIVITIES 15 MIN,5100009,CDM,430,RC,97530GO,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-ACTOS ORAL TABLET 45MG,3204080,CDM,250,RC,,,outpatient,,,40.19,30.14,,32.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.17,32.15,
TRIAMCINOLONE CR. 0.025% 80 GM,3204082,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-CALCIUM CITRATE TABLET 250MG,3204083,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-CARDIZEM LA ORAL TAB ER 240MG,3204084,CDM,250,RC,,,outpatient,,,20.83,15.62,,16.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.38,16.66,
NF-MODAFINIL ORAL TABLET 200MG,3204085,CDM,250,RC,,,outpatient,,,147.65,110.74,,118.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.41,118.12,
NF-SUDOGEST PE ORAL TABLET 10MG,3204086,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-NAMZARIC CAP ER 28MG-10MG,3204087,CDM,250,RC,,,outpatient,,,57.11,42.83,,45.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.98,45.69,
NF-CO Q-10 ORAL CAPSULE 200MG,3204088,CDM,250,RC,,,outpatient,,,0.74,0.56,,0.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.3,0.59,
NF-NADOLOL         TAB  80MG,3204089,CDM,250,RC,,,outpatient,,,20.39,15.29,,16.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.2,16.31,
NF-HUMIRA SUBCUTANEOUS KIT,3204091,CDM,250,RC,,,outpatient,,,9859.54,7394.66,,7887.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3967.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4929.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5422.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7887.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7394.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3967.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3967.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7887.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7394.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7887.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7887.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3967.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7887.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7887.63,
NF-OSCIMIN DISINTEGRATING TAB 0.125MG,3204092,CDM,250,RC,,,outpatient,,,1.67,1.25,,1.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.67,1.34,
NF-TRINTELLIX ORAL TABLET 20MG,3204093,CDM,250,RC,,,outpatient,,,47.09,35.32,,37.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,37.67,
NF-METHENAMINE HIPPURATE ORAL TABLET 1GM,3204094,CDM,250,RC,,,outpatient,,,7.74,5.81,,6.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.11,6.19,
NF-LUTEIN CAPSULE,3204095,CDM,250,RC,,,outpatient,,,0.47,0.35,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-EFFIENT TAB 5MG,3204097,CDM,250,RC,,,outpatient,,,67.93,50.95,,54.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.34,54.34,
VENLAFAXINE HCL ORAL CAP ER 150MG,3204098,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-Pradaxa Oral Capsule 75MG,3204099,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Mexiletine HCl Capsule 150MG,3204100,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Breo Ellipta Inhalation Powder,3204102,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-GARLIC/LECITHIN CAPSULE,3204103,CDM,250,RC,,,outpatient,,,0.33,0.25,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-SUPER B COMPLEX W/C CAPSULE,3204104,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-Zaleplon Oral Capsule 10MG,3204105,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Methotrexate Oral Tablet 2.5MG,3204106,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Protonix Tablet 40MG,3204107,CDM,250,RC,,,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,46.4,
NF-LOTRISONE CRM 1%-0.05%,3204108,CDM,250,RC,,,outpatient,,,9.02,6.77,,7.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.63,7.22,
NF-Cetirizine Hydrochloride Chew Tab 10M,3204109,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-VITAMIN E CAPSULE 400IU,3204111,CDM,250,RC,,,outpatient,,,0.1,0.08,,0.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.08,
NF-ALL 50 SUPER B COMPLEX TABLET,3204112,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-TRANDOLAPRIL/VERAPAMIL HCL TAB ER 2MG,3204114,CDM,250,RC,,,outpatient,,,24.85,18.64,,19.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10,19.88,
NF-OXCARBAZEPINE ORAL TABLET 300MG,3204115,CDM,250,RC,,,outpatient,,,9.77,7.33,,7.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.93,7.82,
NF-CARDURA TAB 8MG,3204116,CDM,250,RC,,,outpatient,,,20.82,15.62,,16.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.38,16.66,
NF-KETOPROFEN CAP 50MG,3204117,CDM,250,RC,,,outpatient,,,4.13,3.1,,3.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.66,3.3,
NF-MIRTAZAPINE ORAL TABLET 30MG,3204119,CDM,250,RC,,,outpatient,,,12.94,9.71,,10.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.21,10.35,
NF-REQUIP XL ORAL TAB ER 2MG,3204120,CDM,250,RC,,,outpatient,,,20.82,15.62,,16.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.38,16.66,
NF-Exemestane Oral Tablet 25MG,3204122,CDM,250,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Afinitor Oral Tablet 10MG,3204123,CDM,250,RC,,,outpatient,,,2098,1573.5,,1678.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,844.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1049,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1049,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1049,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1049,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1153.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1678.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,844.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,844.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1678.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1573.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1678.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1678.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,844.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1678.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,844.24,1678.4,
CLINIMIX IV SOLN 4.25%-10% 1000ML,3204124,CDM,250,RC,,,outpatient,,,153.55,115.16,,122.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.79,122.84,
NF-Diclofenac Sodium Topical Gel 3%,3204125,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Linzess Oral Capsule 145MCG,3204126,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-LORAZEPAM ORAL SOLUTION 2MG/1ML,3204127,CDM,250,RC,,,outpatient,,,5.92,4.44,,4.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.38,4.74,
SODIUM CHLORIDE IV SOLUTION 0.45%,3204128,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
SOD. CHLOR. 0.45% 250 ML,3204129,CDM,636,RC,,,both,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,2,
NF-TIZANIDINE HCL CAP 2MG,3204130,CDM,250,RC,,,outpatient,,,24.53,18.4,,19.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.87,19.62,
VALSARTAN/HCTZ 320-12.5 MG,3204131,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-LOVAZA LIQ CAP 1GM,3204132,CDM,250,RC,,,outpatient,,,7.08,5.31,,5.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.85,5.66,
NF-TRINTELLIX ORAL TABLET 5MG,3204133,CDM,250,RC,,,outpatient,,,47.09,35.32,,37.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,37.67,
XIFAXAN 550 MG TABLET,3204134,CDM,637,RC,,,outpatient,,,41.06,30.8,,32.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.52,32.85,
NF-HYDROXYCHLOROQUINE SULFATE ORALTAB 20,3204135,CDM,250,RC,,,outpatient,,,15.12,11.34,,12.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.08,12.1,
NF-Carafate Tablet 1GM,3204137,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Omeprazole Delayed Release Capsule 40,3204139,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Lovastatin Tablet 40MG,3204140,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Calcium 600 + D3 Oral Tablet 600MG-80,3204142,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Sertraline Oral Tablet 25MG,3204144,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Refresh Plus Ophthalmic Solution 0.5%,3204145,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-glyBURIDE Tablet 2.5MG,3204146,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Isosorbide Dinitrate Tablet 30MG,3204147,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Rythmol SR Oral Cap ER 225MG,3204148,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Allevyn Gentle Border Device,3204149,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Benztropine Mesylate Oral Tablet 2MG,3204150,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Zantac 300 Tablet 300MG,3204151,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-QUEtiapine Fumarate Oral Tablet 200MG,3204152,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Hydrocortisone Lotion 2.5%,3204153,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-QUEtiapine Fumarate Oral Tablet 200MG,3204154,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-busPIRone Oral Tablet 30MG,3204155,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Levothyroxine Sodium Oral Tablet 175M,3204156,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-TraZODone Oral Tablet 150MG,3204157,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-MEXILETINE HCL CAP 200MG,3204158,CDM,250,RC,,,outpatient,,,11.2,8.4,,8.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.51,8.96,
VENLAFAXINE 75 MG TABLET,3204159,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-FENOFIBRATE ORAL TABLET 48MG,3204160,CDM,250,RC,,,outpatient,,,7.07,5.3,,5.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.84,5.66,
NF-CALCIUM/MAGNESIUM/ZINC TABLET,3204161,CDM,250,RC,,,outpatient,,,0.14,0.11,,0.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.11,
NF-LEFLUNOMIDE ORAL TABLET 20MG,3204162,CDM,250,RC,,,outpatient,,,60.7,45.53,,48.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.43,48.56,
NF-ICY HOT CREAM,3204163,CDM,250,RC,,,outpatient,,,0.48,0.36,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-NICOTINE POLACRILEX MM LOZ 4MG,3204167,CDM,250,RC,,,outpatient,,,2.08,1.56,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.84,1.66,
NF-Calcium 600 + D3 Oral Tablet 600MG-80,3204169,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-NIKKI ORAL TABLET 3MG-0.02MG,3204171,CDM,250,RC,,,outpatient,,,9.36,7.02,,7.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.77,7.49,
NF-Uloric Oral Tablet 40MG,3204173,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-PRAZOSIN HCL CAP 2MG,3204174,CDM,250,RC,,,outpatient,,,10.38,7.79,,8.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.18,8.3,
NF-RASUVO SUBCUTANEOUS SOLUTION 20MG/0.4,3204175,CDM,250,RC,,,outpatient,,,1304.25,978.19,,1043.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,524.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,652.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,652.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,652.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,717.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1043.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,524.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,978.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1043.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1043.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,524.83,1043.4,
NF-Remeron Tablet 15MG,3204176,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Diclofenac Sodium Topical Gel 3%,3204177,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-OXYCONTIN EXTENDED RELEASE TABLET 20M,3204179,CDM,250,RC,,,outpatient,,,22.12,16.59,,17.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.9,17.7,
NF-FERROUS GLUCONATE ORAL TABLET 324MG,3204181,CDM,250,RC,,,outpatient,,,0.27,0.2,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-HYDROCHLOROTHIAZIDE ORAL TABLET 50MG,3204182,CDM,250,RC,,,outpatient,,,0.89,0.67,,0.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.36,0.71,
NF-RISPERDAL M-TAB 2MG,3204183,CDM,250,RC,,,outpatient,,,81.54,61.16,,65.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.81,65.23,
NF-WELLBUTRIN XL ORAL 24 HR TABLET ER 30,3204184,CDM,250,RC,,,outpatient,,,32.39,24.29,,25.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.03,25.91,
NF-Estropipate Tablet 1.5MG,3204185,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-NexIUM Capsule 40MG,3204186,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Lovaza Oral Liquid Filled Capsule 1GM,3204187,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Aldactone Oral Tablet 25MG,3204188,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Benztropine Mesylate Tablet 1MG,3204189,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Keppra Oral Tablet 750MG,3204190,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Lexapro Tablet 10MG,3204191,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Namzaric Oral Cap ER 14MG-10MG,3204192,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-OLANZapine Oral Tablet 10MG,3204194,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Lasix Tablet 20MG,3204195,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Pepcid Oral Tablet 40MG,3204196,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-ONE DAILY MEN'S 50+ ADVANCED ORAL TAB,3204197,CDM,250,RC,,,outpatient,,,0.32,0.24,,0.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.13,0.26,
NF-Cosopt PF Ophthalmic Solution 2%-0.5%,3204198,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NOVOLOG INSULIN 10 ML VIAL,3204199,CDM,637,RC,,,outpatient,,,46.4,34.8,,37.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.67,37.12,
NF-Fenofibrate Oral Tablet 160MG,3204200,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
LIDOCIANE 1.5 % /EPI 1:.200000,3204201,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-TL Gard Rx Oral Tablet 1MG-2.2MG-25MG,3204204,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-TL Gard Rx Oral Tablet 1MG-2.2MG-25MG,3204205,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Jardiance Oral Tablet 10MG,3204206,CDM,250,RC,,,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.35,50.4,
NF-Trintellix Oral Tablet 20MG,3204207,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Cosopt PF Ophthalmic Solution 2%-0.5%,3204209,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Cyclobenzaprine HCl Tablet 10MG,3204210,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
PT THERAPEUTIC ACTIVITES 15 MIN,5100518,CDM,420,RC,97530GP,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Urecholine Tablet 10MG,3204213,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CEFTIN SUSP. 250MG/5ML 100 ML,3204214,CDM,637,RC,,,outpatient,,,272,204,,217.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,149.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,109.45,217.6,
NF-MINOCYCLINE HCL ORAL TABLET ER 135MG,3204216,CDM,250,RC,,,outpatient,,,74.62,55.97,,59.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.03,59.7,
NF-MYCOPHENOLATE MOFETIL CAP 250MG,3204217,CDM,250,RC,,,outpatient,,,14.78,11.09,,11.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.95,11.82,
NF-SEVELAMER CARBONATE ORAL TABLET 800MG,3204218,CDM,250,RC,,,outpatient,,,22.55,16.91,,18.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.07,18.04,
NF-Toprol XL Tablet 25MG,3204219,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DOCUSATE SOD. 50MG/5mL,3204220,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-DIPYRIDAMOLE ORAL TABLET 50MG,3204221,CDM,250,RC,,,outpatient,,,3.48,2.61,,2.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.4,2.78,
NF-Azor Oral Tablet 10MG-40MG,3204223,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Erythromycin Capsule 250MG,3204225,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Movantik Oral Tablet 25MG,3204226,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Humira Subcutaneous Solution 40MG/0.8,3204227,CDM,250,RC,,,outpatient,,,9859,7394.25,,7887.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5422.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7887.2,
NF-Oscimin Disintegrating Tablet 0.125MG,3204228,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-SUMAtriptan Succinate Oral Tablet 50M,3204229,CDM,250,RC,,,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
NF-OSMOLITE 1 CAL LIQUID,3204231,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-OMEPRAZOLE DELAYED RELEASE TABLET 20M,3204232,CDM,250,RC,,,outpatient,,,21.21,15.91,,16.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.53,16.97,
NF-LUTEIN LIQUID FILLED CAPSULE 20MG,3204234,CDM,250,RC,,,outpatient,,,1.19,0.89,,0.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.48,0.95,
NF-MASON NATURAL OMEGA-3 FISH OIL 1200MG,3204235,CDM,250,RC,,,outpatient,,,0.52,0.39,,0.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.21,0.42,
NF-PRAZOSIN HCL CAP 2MG,3204236,CDM,250,RC,,,outpatient,,,3.72,2.79,,2.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.5,2.98,
TRANEXAMIC ACID INJ. 1000MG/NSS 100ML,3204237,CDM,636,RC,,,both,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,140,
NF-Brimonidine Tartrate Ophth Soln 0.15%,3204240,CDM,250,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
NF-Ziks Hematogen Oral Liq Capsule,3204242,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Promacta Oral Tablet 25MG,3204243,CDM,250,RC,,,outpatient,,,508,381,,406.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.42,406.4,
NF-BIOTIN ORAL TABLET 1000MCG,3204244,CDM,250,RC,,,outpatient,,,0.15,0.11,,0.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.12,
NF-Meropenem IV Pwd for Soln 500MG,3204246,CDM,637,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-Zolpidem Tartrate Oral Tab ER 12.5MG,3204248,CDM,637,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Triamterene/HCTZ Capsule 37.5-25MG,3204249,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-PROMACTA ORAL TABLET 50MG,3204250,CDM,250,RC,,,outpatient,,,1111.67,833.75,,889.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,447.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,555.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,555.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,555.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,555.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,611.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,447.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,447.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,889.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,889.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,447.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,889.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,447.34,889.34,
NF-ZESTRIL ORAL TABLET 5MG,3204251,CDM,250,RC,,,outpatient,,,56.48,42.36,,45.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.73,45.18,
BUPROPION XL 300 MG,3204252,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Zoloft Tablet 25MG,3204253,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Fioricet with Codeine Oral Capsule,3204254,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-PHENobarbital Oral Tablet 64.8MG,3204255,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
TRETINOIN CR. 0.025% 20 GM,3204256,CDM,637,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Nystatin Powder,3204257,CDM,250,RC,,,outpatient,,,20562,15421.5,,16449.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8274.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10281,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10281,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10281,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10281,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11309.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16449.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15421.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15421.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15421.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15421.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8274.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8274.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16449.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15421.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16449.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16449.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8274.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,16449.6,
NF-KlonoPIN Tablet 1MG,3204258,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Vyvanse Oral Capsule 50MG,3204259,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Zolpidem Tartrate Oral Tablet 10MG,3204260,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Glimepiride Oral Tablet 1MG,3204263,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-amLODIPine-valsart-HCTZ Tab 10-320-25,3204264,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204265,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204266,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-Proair HFA Inh Susp 0.09MG/1Act,3204267,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
EVAL RX FOR COMMNICTN DEVICE EA ADD HOUR,5100635,CDM,440,RC,92608GN,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
ETHYL CHLORIDE PINPOINT SPRAY,3204269,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SATURATION CHECK MULTIPLE,5200071,CDM,460,RC,94761,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,80,
NF-Jentadueto Oral Tablet 2.5MG-850MG,3204271,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Propafenone HCl Tablet 150MG,3204272,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Anoro Ellipta Inhalation Powder,3204273,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Humira Subcutaneous Solution 40MG/0.8,3204274,CDM,250,RC,,,outpatient,,,9859,7394.25,,7887.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4929.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5422.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3967.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7887.2,
NF-Oscimin Disintegrating Tablet 0.125MG,3204275,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Astelin Ready-Spray Nasal,3204276,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-NexIUM Capsule 20MG,3204277,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Trintellix Oral Tablet 20MG,3204278,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
DICYCLOMINE HCL 20MG/10ML  SOLUTION,3204279,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Combivent Inh Aer Pwd 103MCG-18MCG/1,3204280,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Fenofibrate Oral Tablet 54MG,3204282,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3204285,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Ilevro Ophthalmic Suspension 0.3%,3204286,CDM,250,RC,,,outpatient,,,645,483.75,,516,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,259.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,322.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,354.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,259.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,483.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,259.55,516,
NF-Spironolactone Oral Tablet 50MG,3204287,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Theophylline Oral Tab ER 300MG,3204288,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-TraZODone Hydrochloride Tablet 150MG,3204290,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Dexilant Delayed-Release Capsule 60MG,3204291,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Dexilant Delayed-Release Capsule 60MG,3204292,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Dexilant Delayed-Release Capsule 60MG,3204293,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-PROPRANOLOL HCL CAP ER 60MG,3204294,CDM,250,RC,,,outpatient,,,11.46,8.6,,9.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.61,9.17,
NF-Entresto Oral Tablet 24MG-26MG,3204295,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-NexIUM Capsule 40MG,3204296,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Esomeprazole Magnesium Oral Cap DR 40,3204297,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-ALPRAZolam Oral Tablet 1MG,3204298,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3204299,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Amitriptyline Oral Tablet 50MG,3204300,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
ENTRESTO 24MG/26MG,3204302,CDM,637,RC,,,outpatient,,,10.23,7.67,,8.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.12,8.18,
NF-Brimonidine Tartrate Ophth Soln 0.15%,3204304,CDM,250,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
NF-HCTZ/Triamterene Tablet 25MG-37.5MG,3204305,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204307,CDM,250,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
OCELLA 28 DAY,3204308,CDM,637,RC,,,outpatient,,,50.48,37.86,,40.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.31,40.38,
NF-Letrozole Oral Tablet 2.5MG,3204310,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Pradaxa Oral Capsule 75MG,3204316,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Mexiletine HCl Capsule 150MG,3204317,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Vraylar Oral Capsule 4.5MG,3204318,CDM,250,RC,,,outpatient,,,162,121.5,,129.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.19,129.6,
NF-Vraylar Oral Capsule 6MG,3204319,CDM,250,RC,,,outpatient,,,162,121.5,,129.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.19,129.6,
NF-Pyridostigmine Bromide Oral Tablet 60,3204320,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Pyridostigmine Bromide Oral Tablet 60,3204322,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Pepcid Oral Tablet 40MG,3204328,CDM,637,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Albuterol Inhaler 0.09MG/Inh,3204329,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Anoro Ellipta Inhalation Powder,3204330,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Meloxicam Oral Suspension 7.5MG/5ML,3204331,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Lyrica Oral Capsule 200MG,3204332,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-TraZODone Hydrochloride Tablet 150MG,3204333,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
DEBRIDEMENT OF INFECTED SKIN,6000106,CDM,521,RC,11000,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,1365.74,
NF-Mirtazapine Oral Tablet 15MG,3204336,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Bentyl Tablet 20MG,3204337,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Glimepiride Oral Tablet 1MG,3204338,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Letrozole Oral Tablet 2.5MG,3204339,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-PIMOZIDE ORAL TABLET 2MG,3204341,CDM,250,RC,,,outpatient,,,9.03,6.77,,7.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.63,7.22,
NF-Otezla Oral Tablet 30MG,3204342,CDM,250,RC,,,outpatient,,,229,171.75,,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,92.15,183.2,
NF-pimozide Oral Tablet 2MG,3204343,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Propranolol Hydrochloride Cap ER 160M,3204344,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3204345,CDM,250,RC,,,outpatient,,,378,283.5,,302.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.11,302.4,
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act,3204349,CDM,250,RC,,,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.84,79.2,
NF-Livalo Oral Tablet 2MG,3204351,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-PARoxetine HCl Tablet 30MG,3204352,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
"NF-CoQ-10 Oral Capsule, Liquid Filled 40",3204357,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Colchicine Oral Capsule 0.6MG,3204362,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-NexIUM Capsule 40MG,3204363,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Genteal Ophthalmic Gel 0.25%-0.3%,3204365,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Pataday Ophthalmic Solution 0.2%,3204366,CDM,250,RC,,,outpatient,,,295,221.25,,236,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,118.71,236,
NF-Systane Ophthalmic Gel/Jelly 0.3%,3204367,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
"NF-Procrit Injection 10,000U/ML",3204368,CDM,250,RC,,,outpatient,,,1088,816,,870.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,598.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,437.81,870.4,
NF-OCREVUS INTRAVENOUS SOLUTION 30MG/1ML,3204370,CDM,250,RC,,,outpatient,,,7215,5411.25,,5772,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3968.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5772,
NF-Pradaxa Oral Capsule 75MG,3204371,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Abilify Oral Tablet 2MG,3204372,CDM,250,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
ELETRIPTAN 20 MG TABLET,3204373,CDM,637,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Sucralfate Oral Tablet 1GM,3204376,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Ketoconazole Oral Tablet 200MG,3204377,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-SE-TAN PLUS ORAL CAPSULE,3204378,CDM,250,RC,,,outpatient,,,2.07,1.55,,1.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.83,1.66,
LIDOCAINE 1% (50 MG/5ML) 5 ML VIAL,3204380,CDM,250,RC,,,outpatient,,,8.85,6.64,,7.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.56,7.08,
BUPIVICAINE 0.25% 30 ML,3204381,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Allegra Oral Tablet 60MG,3204382,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204385,CDM,637,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-Methenamine Mandelate Oral Tablet 1GM,3204388,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Methenamine Mandelate Oral Tablet 1GM,3204389,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Linzess Oral Capsule 145MCG,3204390,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-OLANZapine Oral Tablet 10MG,3204392,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-OLANZapine Oral Tablet 10MG,3204393,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Tresiba Subcutaneous Solution 100U/1M,3204394,CDM,250,RC,,,outpatient,,,131,98.25,,104.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.71,104.8,
NF-Pravastatin Sodium Oral Tablet 80MG,3204395,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-hydrALAZINE HCl Tab 50MG,3204396,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Tradjenta Oral Tablet 5MG,3204399,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Oscimin Disintegrating Tablet 0.125MG,3204402,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Humira SubQ Kit 40MG/0.8ML,3204403,CDM,250,RC,,,outpatient,,,10815,8111.25,,8652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5948.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8652,
NF-Maxitrol Ophthalmic Ointment,3204404,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Lumigan Solution Ophthalmic 0.03%,3204405,CDM,250,RC,,,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
NF-Pataday Ophthalmic Solution 0.2%,3204406,CDM,250,RC,,,outpatient,,,312,234,,249.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.55,249.6,
NF-Restasis Ophthalmic Emulsion 0.05%,3204407,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Denavir Topical Cream 1%,3204408,CDM,250,RC,,,outpatient,,,288,216,,230.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.89,230.4,
NF-Asmanex Twist Inh/Neb Powder 220MCG/A,3204411,CDM,250,RC,,,outpatient,,,683,512.25,,546.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,341.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,274.84,546.4,
NF-lamoTRIgine Oral Tablet 25MG,3204414,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Spiriva Respimat Inh Spray 1.25MCG/1A,3204415,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3204416,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Jardiance Oral Tablet 25MG,3204417,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Entresto Oral Tablet 49MG-51MG,3204418,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204419,CDM,250,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204420,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Marinol Capsule 2.5MG,3204421,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
MUPIROCIN OINT 2% 22 GM,3204423,CDM,637,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Propranolol Hydrochloride Cap ER 160M,3204424,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Marinol Capsule 2.5MG,3204425,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-TIKOSYN CAP 250MCG,3204427,CDM,250,RC,,,outpatient,,,46.14,34.61,,36.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.57,36.91,
NF-Prazosin Oral Capsule 2MG,3204428,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-TraZODone HCl Oral Tablet 150MG,3204429,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-TAMBOCOR ORAL TABLET 50MG,3204431,CDM,250,RC,,,outpatient,,,10.25,7.69,,8.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.12,8.2,
NF-Rasagiline Oral Tablet 1MG,3204433,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Promacta Oral Tablet 25MG,3204436,CDM,250,RC,,,outpatient,,,508,381,,406.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.42,406.4,
NF-Nuedexta Oral Capsule 20MG-10MG,3204438,CDM,250,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Anoro Ellipta Inhalation Powder,3204439,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Zaditor Ophthalmic Solution 0.025%,3204440,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Systane Ophth Solution,3204441,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
MELATONIN 10 MG,3204442,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
HEPARIN LOCK FLUSH 100 U/ML VIAL,3204444,CDM,250,RC,,,outpatient,,,5.4,4.05,,4.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.17,4.32,
NF-Seasonique Oral Tab 30MCG-0.15MG-0.01,3204446,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Restasis Multidose Ophth Emulsion 0.0,3204447,CDM,250,RC,,,outpatient,,,344,258,,275.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,138.43,275.2,
NF-APAP/oxyCODONE Tablet,3204448,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-UTA CAP 0.12-120-10-40.8MG,3204452,CDM,250,RC,,,outpatient,,,13.76,10.32,,11.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.54,11.01,
NF-Tresiba Subcutaneous Solution 100U/1M,3204455,CDM,250,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
CYANOCOBALAMIN 1000MCG/ML 30 ML VIAL,3204456,CDM,637,RC,,,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
NF-Align Oral Capsule 4MG,3204459,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204460,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Genvoya Oral Tablet,3204463,CDM,250,RC,,,outpatient,,,435,326.25,,348,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.04,348,
NF-Methotrexate Oral Tablet 2.5MG,3204464,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Prezista Oral Tablet 800MG,3204466,CDM,250,RC,,,outpatient,,,233,174.75,,186.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,93.76,186.4,
NF-Norvir Oral Tablet 100MG,3204467,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-Truvada Oral Tablet 200MG-300MG,3204468,CDM,250,RC,,,outpatient,,,248,186,,198.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.8,198.4,
NF-Pataday Ophthalmic Solution 0.2%,3204470,CDM,250,RC,,,outpatient,,,312,234,,249.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.55,249.6,
"NF-Procrit Injection 10,000U/ML",3204471,CDM,250,RC,,,outpatient,,,1142,856.5,,913.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,628.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,459.54,913.6,
NF-Systane Ophthalmic Gel/Jelly 0.3%,3204472,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Sensipar Oral Tablet 30MG,3204473,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Rasagiline Mesylate Oral Tablet 0.5MG,3204474,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
DEBRIDMENT,6000107,CDM,360,RC,11042,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,990.21,
NF-VANCOMYCIN HCL CAP 125MG,3204477,CDM,637,RC,,,outpatient,,,115.9,86.93,,92.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.64,92.72,
NF-Vimpat Oral Tablet 150MG,3204480,CDM,250,RC,,,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.35,50.4,
NF-Truvada Oral Tablet 200MG-300MG,3204481,CDM,250,RC,,,outpatient,,,248,186,,198.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.8,198.4,
NF-Vimpat Oral Tablet 150MG,3204484,CDM,250,RC,,,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.35,50.4,
NF-Truvada Oral Tablet 200MG-300MG,3204485,CDM,250,RC,,,outpatient,,,248,186,,198.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.8,198.4,
NF-Methotrexate Oral Tablet 2.5MG,3204486,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Cetirizine Oral Tab 10MG,3204488,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Mitigare Oral Capsule 0.6MG,3204489,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-POTASSIUM PHOSPHATE INJECTION 3MM/ML,3204490,CDM,250,RC,,,outpatient,,,4.31,3.23,,3.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.73,3.45,
NF-Arimidex Tablet 1MG,3204491,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Trintellix Oral Tablet 10MG,3204492,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
HUMULIN N 1 UNIT,3204494,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Myrbetriq Oral Tablet 25MG,3204495,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Rexulti Oral Tablet 4MG,3204496,CDM,250,RC,,,outpatient,,,149,111.75,,119.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.96,119.2,
NF-Esgic Oral Capsule 325MG-50MG-40MG,3204497,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Phentermine Oral Tablet 37.5MG,3204498,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Ketotifen Fumarate Ophth Solution 0.0,3204499,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Viibryd Oral Tablet 40MG,3204502,CDM,250,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
NF-Janumet Oral Tablet 50MG-1000MG,3204503,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Vascepa Oral Liquid Filled Cap 1GM,3204504,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
REMOVAL SKIN TAGS UP TO 15,6000111,CDM,521,RC,11200,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,266.88,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3204506,CDM,250,RC,,,outpatient,,,408,306,,326.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,164.18,326.4,
NF-Strattera Oral Capsule 60MG,3204507,CDM,250,RC,,,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.35,50.4,
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act,3204509,CDM,250,RC,,,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.65,84.8,
NF-Apidra Injection Solution 100U/1ML,3204510,CDM,250,RC,,,outpatient,,,119,89.25,,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.89,95.2,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204511,CDM,250,RC,,,outpatient,,,348,261,,278.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.04,278.4,
NF-Decara Oral Liquid Capsule 50000IU-14,3204513,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Promacta Oral Tablet 25MG,3204514,CDM,250,RC,,,outpatient,,,508,381,,406.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.42,406.4,
NF-Breo Ellipta Inhalation Powder,3204515,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Restasis Ophthalmic Emulsion 0.05%,3204516,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Fenofibrate Oral Tablet 160MG,3204518,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Fenofibrate Micronized Cap 134MG,3204520,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
SHAVING SKIN LESION <0.5 CM,6000112,CDM,521,RC,11300,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,551.37,
NF-BACLOFEN ORAL TAB 20MG,3204522,CDM,250,RC,,,outpatient,,,5.04,3.78,,4.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.03,4.03,
NF-LaMICtal ODT Disintegrating Tablet 25,3204523,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
CALCIUM CHLORIDE 10% 10 ML,3204525,CDM,250,RC,,,outpatient,,,84.92,63.69,,67.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.17,67.94,
NF-NOVOLIN 70/30 SUBQ SUSP 70U-30U/1ML,3204526,CDM,250,RC,,,outpatient,,,28.15,21.11,,22.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.33,22.52,
NF-Potassium Citrate Oral Tablet ER 10ME,3204527,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3204529,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Methylfolate Oral Capsule 2000MCG,3204530,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-pimozide Oral Tablet 2MG,3204531,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Fenofibrate Oral Capsule 200MG,3204532,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-pimozide Oral Tablet 2MG,3204533,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
AMOXICILLIN 400MG/5ML 100ML,3204534,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3204537,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Lisinopril Tablet 20mg,3204539,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-ISOMETHEPTENE-CAFF-APAP 65MG-20MG-325,3204540,CDM,250,RC,,,outpatient,,,21.84,16.38,,17.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.79,17.47,
NF-ORPHENADRINE CITRATE ORAL TAB ER 100M,3204541,CDM,250,RC,,,outpatient,,,8.63,6.47,,6.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.47,6.9,
NF-Anoro Ellipta Inhalation Powder,3204542,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
"NF-Isometh Mucate,Caff,APAP Tab 65-20-32",3204543,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Orphenadrine Citrate Tablet 100MG,3204544,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Levocetirizine Dihydrochloride Tab 5M,3204545,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Jentadueto XR Oral Tablet ER 5MG-1000,3204546,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Jardiance Oral Tablet 25MG,3204547,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204548,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
CAFFEINE CITRATE 20MG/ML,3204549,CDM,250,RC,,,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
NF-TOPAMAX CAP 15MG,3204550,CDM,250,RC,,,outpatient,,,9.55,7.16,,7.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.84,7.64,
NF-TRULANCE ORAL TABLET 3MG,3204551,CDM,250,RC,,,outpatient,,,57.49,43.12,,45.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.13,45.99,
NF-Fenofibrate Micronized Cap 134MG,3204552,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Onglyza Oral Tablet 5MG,3204553,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Uloric Oral Tablet 40MG,3204554,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Promacta Oral Tablet 25MG,3204556,CDM,250,RC,,,outpatient,,,508,381,,406.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.42,406.4,
NF-Klor-Con Powder 20MEQ,3204557,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-BASAGLAR KWIKPEN SUBQ SOLN 100U/1ML,3204559,CDM,250,RC,,,outpatient,,,96.59,72.44,,77.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.87,77.27,
NF-Eucrisa Topical application Ointment,3204560,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Neurontin Capsule 300MG,3204561,CDM,637,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Glyxambi Oral Tablet 25MG-5MG,3204566,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
SHAVING LESION 0.6-1.0CM,6000118,CDM,521,RC,11311,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,266.87,
NF-Dok Plus Tablets,3204570,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Carbidopa/Levodopa Tablet 50MG-200MG,3204571,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Contour Blood Glucose Monitoring Syst,3204573,CDM,250,RC,,,outpatient,,,266,199.5,,212.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.04,212.8,
NF-Invokana Oral Tablet 300MG,3204574,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Oxybutynin Chloride Oral Tab ER 10MG,3204576,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Testosterone Cypionate IM Oil 200MG/1,3204577,CDM,637,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Amaryl Tablet 1MG,3204578,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Amaryl Tablet 1MG,3204580,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Amaryl Tablet 1MG,3204581,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Trelegy Ellipta Inhalation Powder,3204582,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
CEFOXOTIN 2 GM,3204583,CDM,636,RC,,,both,,,53.3,39.98,,42.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.45,53.3,
NF-Trintellix Oral Tablet 20MG,3204584,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Stiolto Respimat Inst Pack 28ACT,3204585,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Promacta Oral Tablet 25MG,3204586,CDM,250,RC,,,outpatient,,,508,381,,406.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.42,406.4,
NF-Promacta Oral Tablet 25MG,3204587,CDM,637,RC,,,outpatient,,,508,381,,406.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.42,406.4,
NF-Trintellix Oral Tablet 10MG,3204589,CDM,637,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Trintellix Oral Tablet 10MG,3204590,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Viberzi Oral Tablet 75MG,3204591,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Adipex-P Oral Tablet 37.5MG,3204592,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-ADIPEX-P ORAL TABLET 37.5MG,3204593,CDM,250,RC,,,outpatient,,,9.97,7.48,,7.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.01,7.98,
NF-Valsartan/HCTZ Oral Tablet 80MG-12.5M,3204594,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-VALSARTAN AND HYDROCHLOROTHIAZIDE TAB,3204595,CDM,250,RC,,,outpatient,,,14.55,10.91,,11.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.85,11.64,
NF-Linzess Oral Capsule 145MCG,3204596,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
CEFAZOLIN 1 GM / D5W 50 ML  PM,3204597,CDM,636,RC,,,both,,,21.86,16.4,,17.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.8,21.86,
NF-Brimonidine Tartrate Ophth Soln 0.15%,3204598,CDM,250,RC,,,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.48,94.4,
NF-Brimonidine Tartrate Ophth Soln 0.15%,3204600,CDM,637,RC,,,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.48,94.4,
NF-Nalfon Oral Capsule 400MG,3204603,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Xyzal Oral Tablet 5MG,3204604,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
TRUVADA 200MG/300MG,3204605,CDM,637,RC,,,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,200,
NF-Humira Subcutaneous Solution 40MG/0.8,3204606,CDM,250,RC,,,outpatient,,,10815,8111.25,,8652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5948.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8652,
NORETHINDRONE 0.35 MG 28,3204608,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Breo Ellipta Inhalation Powder,3204609,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Restasis Ophthalmic Emulsion 0.05%,3204610,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NEW PT LEVEL 1 OV,6000252,CDM,521,RC,99201,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
BACITRACIN INJECTION 50000 UNITS,3204612,CDM,636,RC,,,both,,,49.25,36.94,,39.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.82,49.25,
NF-PHILLIPS' MILK OF MAGNESIA 1200MG/15M,3204613,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3204614,CDM,250,RC,,,outpatient,,,408,306,,326.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,164.18,326.4,
NF-Sensipar Oral Tablet 30MG,3204615,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Amitiza Oral Liquid Filled Capsule 8M,3204616,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Viibryd Oral Tablet 40MG,3204617,CDM,250,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
NF-Livalo Oral Tablet 4MG,3204619,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Pradaxa Oral Capsule 75MG,3204620,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-TraZODone HCl Oral Tablet 150MG,3204621,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Tikosyn Oral Capsule 250MCG,3204623,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Letrozole Oral Tablet 2.5MG,3204624,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Namenda XR Oral Capsule ER 14MG,3204625,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Namzaric Oral Cap ER 14MG-10MG,3204626,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Sensipar Oral Tablet 30MG,3204627,CDM,250,RC,,,outpatient,,,119,89.25,,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.89,95.2,
NF-Veltassa PowderforSuspension 8.4GM/1P,3204628,CDM,250,RC,,,outpatient,,,148,111,,118.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.56,118.4,
NF-ACAMPROSATE CALCIUM ORAL TAB DR 333MG,3204630,CDM,250,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
NF-Xeljanz XR Oral Tablet ER 11MG,3204631,CDM,250,RC,,,outpatient,,,606,454.5,,484.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,303,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,303,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,303,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,303,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,333.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,243.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,484.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,243.85,484.8,
NF-Tikosyn Oral Capsule 250MCG,3204632,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Pataday Ophthalmic Solution 0.2%,3204633,CDM,250,RC,,,outpatient,,,312,234,,249.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.55,249.6,
"NF-Procrit Injection 10,000U/ML",3204634,CDM,250,RC,,,outpatient,,,1142,856.5,,913.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,628.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,913.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,459.54,913.6,
NF-Azor Oral Tablet 5MG-40MG,3204636,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Dexilant Delayed-Release Capsule 60MG,3204637,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Azor Oral Tablet 5MG-40MG,3204638,CDM,637,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Dexilant Delayed-Release Capsule 60MG,3204639,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204640,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-Jardiance Oral Tablet 25MG,3204641,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Anoro Ellipta Inhalation Powder,3204642,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3204644,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Victoza Subcutaneous Solution 6MG/1ML,3204645,CDM,250,RC,,,outpatient,,,397,297.75,,317.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,159.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,159.75,317.6,
NF-Perforomist Inhalation Soln 20MCG/2ML,3204646,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-Tikosyn Oral Capsule 250MCG,3204647,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
GABAPENTIN 800 MG,3204649,CDM,637,RC,,,outpatient,,,3.75,2.81,,3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.51,3,
NF-Stiolto Respimat Inst Pack 28ACT,3204650,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Trintellix Oral Tablet 20MG,3204651,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Pataday Ophthalmic Solution 0.2%,3204652,CDM,250,RC,,,outpatient,,,312,234,,249.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.55,249.6,
NF-Rozerem Oral Tablet 8MG,3204654,CDM,250,RC,,,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,44,
NF-Xifaxan Oral Tablet 550MG,3204657,CDM,250,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
NF-Atenolol/Chlorthalidone Tab 100MG-25M,3204658,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Fenofibrate Oral Tablet 160MG,3204659,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-NARATRIPTAN HCL TAB 1MG,3204660,CDM,250,RC,,,outpatient,,,251.21,188.41,,200.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.09,200.97,
NF-RIBOFLAVIN ORAL TABLET 100MG,3204661,CDM,250,RC,,,outpatient,,,0.18,0.14,,0.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.07,0.14,
NF-VITAMIN B-12 ORAL TABLET 100MCG,3204662,CDM,250,RC,,,outpatient,,,0.08,0.06,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-metFORMIN Hydrochloride Tab ER 1000MG,3204663,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Jardiance Oral Tablet 25MG,3204664,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Breo Ellipta Inhalation Powder,3204665,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3204666,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Folbee Tablet 1MG-2.5MG-25MG,3204668,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Indapamide Tablet 1.25MG,3204669,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Lunesta Tablet 3MG,3204672,CDM,250,RC,,,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
NF-Tresiba Subcutaneous Solution 100U/1M,3204673,CDM,637,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3204674,CDM,250,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
POLY-HIST DM LIQUID 5 ML,3204675,CDM,637,RC,,,outpatient,,,1.25,0.94,,1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.5,1,
NF-Trintellix Oral Tablet 5MG,3204676,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-busPIRone Oral Tablet 10MG,3204678,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
SUPREP BOWEL PREP KIT,3204680,CDM,637,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-PARoxetine HCl Tablet 30MG,3204681,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Allegra-D 24 Hour Tab ER 180MG-240MG,3204682,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Nature's Blend HiSorb Co-Enzyme Q10 3,3204683,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Perforomist Inhalation Soln 20MCG/2ML,3204684,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-Breo Ellipta Inhalation Powder,3204685,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-tiZANidine HCl Tablet 2MG,3204687,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Dexilant Delayed-Release Capsule 60MG,3204690,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
CLARITIN 5 MG CHEWABLE TAB,3204691,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Dexilant Delayed-Release Capsule 60MG,3204692,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
TRAZODONE 150 MG,3204694,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Humira Subcutaneous Solution 40MG/0.8,3204695,CDM,250,RC,,,outpatient,,,10815,8111.25,,8652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5948.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8652,
NF-Jadenu Oral Tablet 360MG,3204696,CDM,637,RC,,,outpatient,,,694,520.5,,555.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,381.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,279.27,555.2,
NF-Jadenu Oral Tablet 360MG,3204697,CDM,250,RC,,,outpatient,,,694,520.5,,555.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,381.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,279.27,555.2,
NF-Mirtazapine Oral Tablet 30MG,3204698,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-busPIRone HCl Tablet 10MG,3204699,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Refresh Optive Ophthalmic Soln 0.5%-0,3204700,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Synthroid Tab 25MCG,3204701,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-EpiPen Auto-Injector Kit 0.3MG/0.3ML,3204702,CDM,250,RC,,,outpatient,,,1351,1013.25,,1080.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,743.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1013.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1080.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,543.64,1080.8,
NF-Adipex-P Capsule 37.5MG,3204703,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-SEROquel Tablet 300MG,3204704,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
AMOXICILLIN/CLAV POT SUSP 600/42.9 MG,3204707,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Tresiba Subcutaneous Solution 200U/1M,3204708,CDM,250,RC,,,outpatient,,,273,204.75,,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,109.86,218.4,
NF-Zohydro ER Oral Capsule ER 30MG,3204709,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Tresiba Subcutaneous Solution 200U/1M,3204710,CDM,637,RC,,,outpatient,,,273,204.75,,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,109.86,218.4,
NF-Nuedexta Oral Capsule 20MG-10MG,3204711,CDM,250,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Carafate Tablet 1GM,3204712,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-OLANZapine Oral Tablet 2.5MG,3204714,CDM,637,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3204715,CDM,250,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
NAPROXEN DR 500 MG,3204716,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Tikosyn Oral Capsule 250MCG,3204718,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3204719,CDM,250,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3204721,CDM,250,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204722,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-Jardiance Oral Tablet 10MG,3204723,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Revlimid Oral Capsule 25MG,3204724,CDM,250,RC,,,outpatient,,,2940,2205,,2352,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1183.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1470,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1470,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1470,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1470,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1617,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1183.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1183.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2205,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1183.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1183.06,2352,
NF-Azor Oral Tablet 5MG-40MG,3204725,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Dexilant Delayed-Release Capsule 60MG,3204726,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Farxiga Oral Tablet 5MG,3204727,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-PRAVACHOL TABLET 10MG,3204728,CDM,250,RC,,,outpatient,,,23.62,17.72,,18.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.5,18.9,
NF-BUMETANIDE TAB 2MG,3204731,CDM,250,RC,,,outpatient,,,10.98,8.24,,8.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.42,8.78,
NF-Spironolactone Tablet 50MG,3204732,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Dexilant Delayed-Release Capsule 60MG,3204734,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Bumetanide Oral Tablet 2MG,3204735,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Dronabinol Liquid Filled Capsule 2.5M,3204736,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Adderall Oral Tablet,3204738,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Adderall Oral Tablet 30MG,3204739,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Basaglar KwikPen SubQ Soln 100U/1ML,3204740,CDM,637,RC,,,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.63,76.8,
NF-Brimonidine Tartrate Ophth Soln 0.2%,3204741,CDM,637,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-PRISTIQ EXTENDED-RELEASE TABLET 100MG,3204742,CDM,250,RC,,,outpatient,,,56.49,42.37,,45.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.73,45.19,
NF-NICORETTE ORAL GUM 2MG,3204743,CDM,250,RC,,,outpatient,,,2.01,1.51,,1.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.81,1.61,
NF-Stiolto Respimat Inst Pack 28ACT,3204744,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Trintellix Oral Tablet 20MG,3204745,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Anoro Ellipta Inhalation Powder,3204746,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-VP-Vite Rx Oral Tablet,3204747,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
THYROID 30 MG,3204748,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-ACTOS ORAL TABLET 15MG,3204749,CDM,250,RC,,,outpatient,,,57.51,43.13,,46.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.14,46.01,
NF-MODAFINIL ORAL TABLET 100MG,3204750,CDM,250,RC,,,outpatient,,,81.48,61.11,,65.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.79,65.18,
NF-METAXALONE ORAL TABLET 800MG,3204751,CDM,250,RC,,,outpatient,,,13.98,10.49,,11.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.18,
NF-Farxiga Oral Tablet 10MG,3204752,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Alogliptin Benzoate Oral Tablet 25MGM,3204753,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-DAPTOmycin IV Pwd for Soln 500MG,3204754,CDM,250,RC,,,outpatient,,,1977,1482.75,,1581.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1087.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,795.54,1581.6,
NF-Aptiom Oral Tablet 600MG,3204755,CDM,250,RC,,,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.32,108,
NF-bimatoprost Ophthalmic Solution 0.03%,3204756,CDM,250,RC,,,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.08,159.2,
NF-Metaxalone Oral Tablet 800MG,3204758,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Amitiza Oral Liquid Filled Capsule 8M,3204759,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act,3204760,CDM,250,RC,,,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.65,84.8,
NF-Pradaxa Oral Capsule 75MG,3204761,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3204762,CDM,250,RC,,,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.54,114.4,
NF-Tresiba Subcutaneous Solution 200U/1M,3204763,CDM,637,RC,,,outpatient,,,286,214.5,,228.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,143,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.09,228.8,
NF-Asmanex HFA Inh Aer Powder 200MCG/1AC,3204764,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
MONTELUKAST ORAL GRANULES 4 MG,3204765,CDM,637,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
NF-Morphine Sulfate Oral Solution 20MG/1,3204766,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Omeprazole Oral Tablet DR 20MG,3204767,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trulance Oral Tablet 3MG,3204768,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-OCREVUS INTRAVENOUS SOLUTION 30MG/1ML,3204769,CDM,250,RC,,,outpatient,,,7215,5411.25,,5772,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3968.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5772,
NF-OCREVUS IV SOLN 30MG/1ML,3204770,CDM,250,RC,,,outpatient,,,7215,5411.25,,5772,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3607.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3968.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5411.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2903.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5772,
NF-Humira Subcutaneous Solution 40MG/0.8,3204771,CDM,250,RC,,,outpatient,,,10815,8111.25,,8652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5948.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8111.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4351.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8652,
CEFDINIR ORAL SUSP. 125MG/5ML  100ML,3204772,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-METHOTREXATE   TAB  2.5MG,3204773,CDM,250,RC,,,outpatient,,,13.19,9.89,,10.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.31,10.55,
NF-Juven Oral Powder for Solution,3204774,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Vytorin Oral Tablet 10MG-40MG,3204775,CDM,250,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
NF-Lovaza Oral Liquid Filled Capsule 1GM,3204776,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Tikosyn Oral Capsule 250MCG,3204777,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulance Oral Tablet 3MG,3204778,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Singulair Tablet 10MG,3204779,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Linzess Oral Capsule 290MCG,3204782,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Letrozole Oral Tablet 2.5MG,3204783,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Trelegy Ellipta Inhalation Powder,3204784,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Nuedexta Oral Capsule 20MG-10MG,3204785,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Trelegy Ellipta Inhalation Powder,3204786,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Trintellix Oral Tablet 10MG,3204787,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Dexilant Delayed-Release Capsule 60MG,3204788,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Verapamil HCl Tablet 80MG,3204789,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PAROEX ORAL RINSE 473 ML,3204790,CDM,637,RC,,,outpatient,,,7.35,5.51,,5.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.96,5.88,
NF-Nuedexta Oral Capsule 20MG-10MG,3204791,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Acetasol HC Otic Solution 2%-1%,3204792,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Nuedexta Oral Capsule 20MG-10MG,3204793,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NYSTATIN CREAM 30 GM,3204794,CDM,637,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204795,CDM,250,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204796,CDM,250,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204797,CDM,637,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204798,CDM,637,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
NF-Anoro Ellipta Inhalation Powder,3204799,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204800,CDM,250,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
EST LEVEL 2 OV,6000260,CDM,521,RC,99212,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,134.33,
NF-Vraylar Oral Capsule 3MG,3204803,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Se-Tan PLUS Oral Capsule,3204804,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Stiolto Respimat Inst Pack 28ACT,3204805,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Trintellix Oral Tablet 20MG,3204806,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Prazosin HCl Capsule 2MG,3204807,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Clobetasol Propionate Cream 0.05%,3204809,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Glimepiride Oral Tablet 1MG,3204810,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Breo Ellipta Inhalation Powder,3204811,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Lidocaine Topical application Cream 5,3204812,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Pazeo Ophthalmic Solution 0.7%,3204814,CDM,250,RC,,,outpatient,,,320,240,,256,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.77,256,
NF-Refresh Celluvisc Solution,3204815,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PESSARY,6100032,CDM,521,RC,A4562,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Remeron Tablet 15MG,3204817,CDM,637,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Se-Tan PLUS Oral Capsule,3204818,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3204819,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Entresto Oral Tablet 97MG-103MG,3204821,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Imiquimod Topical Cream 5%,3204822,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Corlanor Oral Tablet 5MG,3204823,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Mexiletine HCl Capsule 200MG,3204824,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Progesterone Oral Capsule 100MG,3204825,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Cosopt PF Ophthalmic Solution 2%-0.5%,3204826,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Levocetirizine Dihydrochloride Tab 5M,3204827,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Wellbutrin SR 12 Hr Tab ER 150MG,3204828,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-DEXTROSE-SODIUM CHLORIDE IV SOLN 5%-0,3204829,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-HYDROcodone-Acetaminophen 7.5-325MG/1,3204830,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Edarbyclor Oral Tablet 40MG-25MG,3204831,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Nuedexta Oral Capsule 20MG-10MG,3204832,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Nuedexta Oral Capsule 20MG-10MG,3204833,CDM,637,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Invokana Oral Tablet 100MG,3204835,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Trelegy Ellipta Inhalation Powder,3204836,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
DEX 4 GLUCOSE GEL 15 GRAMS,3204837,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
TRIAMCINOLONE 0.1% CREAM  454 GM,3204838,CDM,637,RC,,,outpatient,,,26.75,20.06,,21.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.76,21.4,
NF-PRISTIQ TAB ER 50MG,3204839,CDM,250,RC,,,outpatient,,,51.62,38.72,,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.77,41.3,
NF-Zioptan Ophthalmic Solution 0.0015%,3204840,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Biktarvy Oral Tab 50MG-200MG-25MG,3204842,CDM,250,RC,,,outpatient,,,435,326.25,,348,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.04,348,
NF-Vitamin D3 Oral Capsule 50000IU,3204844,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-ZyrTEC Oral Tablet 10MG,3204845,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Cholecalciferol Crystal,3204846,CDM,250,RC,,,outpatient,,,1071,803.25,,856.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,535.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,535.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,535.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,535.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,589.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,430.97,856.8,
NF-UROCIT-K 15 TAB ER 15MEQ,3204848,CDM,250,RC,,,outpatient,,,16.17,12.13,,12.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.51,12.94,
NF-Tresiba Subcutaneous Solution 100U/1M,3204849,CDM,250,RC,,,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.54,114.4,
NF-Linzess Oral Capsule 145MCG,3204850,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Bactrim DS Oral Tablet 800MG-160MG,3204851,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Tikosyn Oral Capsule 250MCG,3204852,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Remeron Tablet 15MG,3204853,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Tradjenta Oral Tablet 5MG,3204854,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Breo Ellipta Inhalation Powder,3204855,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Breo Ellipta Inhalation Powder,3204856,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Movantik Oral Tablet 25MG,3204857,CDM,250,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
NF-Stiolto Respimat Inst Pack 28ACT,3204859,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Trintellix Oral Tablet 20MG,3204860,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Xarelto Oral Tablet 2.5MG,3204861,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Linzess Oral Capsule 290MCG,3204863,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Theophylline Oral Tab ER 300MG,3204864,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-ROSIGLITAZONE MALEATE TAB 4MG,3204865,CDM,250,RC,,,outpatient,,,15.91,11.93,,12.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.4,12.73,
NF-Avandia Oral Tablet 4MG,3204866,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-AVANDIA ORAL TABLET 4MG,3204867,CDM,250,RC,,,outpatient,,,10.67,8,,8.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.29,8.54,
NF-Victoza Subcutaneous Solution 6MG/1ML,3204868,CDM,637,RC,,,outpatient,,,429,321.75,,343.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,235.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,172.63,343.2,
NF-Anoro Ellipta Inhalation Powder,3204869,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Myrbetriq Oral Tablet 25MG,3204870,CDM,637,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204871,CDM,250,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
NF-Invokana Oral Tablet 100MG,3204872,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Victoza Subcutaneous Solution 6MG/1ML,3204873,CDM,250,RC,,,outpatient,,,429,321.75,,343.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,235.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,172.63,343.2,
NF-Genvoya Oral Tablet,3204874,CDM,250,RC,,,outpatient,,,435,326.25,,348,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.04,348,
NF-Victoza Subcutaneous Solution 6MG/1ML,3204876,CDM,637,RC,,,outpatient,,,429,321.75,,343.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,235.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,172.63,343.2,
NF-Exemestane Oral Tablet 25MG,3204877,CDM,637,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Letrozole Oral Tablet 2.5MG,3204878,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3204879,CDM,637,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-OXcarbazepine Oral Tablet 150MG,3204880,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Oxybutynin Chloride Oral Tab ER 10MG,3204881,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Myrbetriq Oral Tablet 25MG,3204882,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
PROBIOTIC GUMMY,3204883,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204884,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-OXcarbazepine Oral Tablet 150MG,3204886,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Anoro Ellipta Inhalation Powder,3204887,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Capecitabine Oral Tablet 500MG,3204888,CDM,250,RC,,,outpatient,,,144,108,,115.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.95,115.2,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204889,CDM,250,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
NF-Tradjenta Oral Tablet 5MG,3204890,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Tikosyn Oral Capsule 250MCG,3204891,CDM,637,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3204892,CDM,637,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
BROMPHED SYRUP 5ML,3204895,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
CARAFATE 1 GM TABLET,3204896,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
DEBRIDEMENT OF INFECTED SKIN,6100048,CDM,521,RC,11000,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,1365.74,
NF-Nuedexta Oral Capsule 20MG-10MG,3204898,CDM,637,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Tradjenta Oral Tablet 5MG,3204899,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Tradjenta Oral Tablet 5MG,3204900,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-PREVALITE POWDER 4GM/5.5GM,3204901,CDM,250,RC,,,outpatient,,,18.92,14.19,,15.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.61,15.14,
ROPINIROLE 4 MG,3204902,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Anoro Ellipta Inhalation Powder,3204903,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Co Q-10 Capsule 10MG,3204904,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3204906,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Symbyax Capsule 6MG-50MG,3204907,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-sulfaSALAzine Oral Tablet 500MG,3204909,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-THYROID TABLET 65MG,3204910,CDM,250,RC,,,outpatient,,,1.56,1.17,,1.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.63,1.25,
HYDRALAZINE HCL 50 MG TAB,3204911,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SPIRONOLACTONE 50 MG TAB,3204912,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Valsartan/HCTZ Oral Tablet 80MG-12.5M,3204913,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Breo Ellipta Inhalation Powder,3204914,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Nuedexta Oral Capsule 20MG-10MG,3204915,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Adderall Oral Tablet 30MG,3204917,CDM,637,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Dexilant Delayed-Release Capsule 60MG,3204918,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-GALANTAMINE HBR CAPSULE ER 8MG,3204919,CDM,250,RC,,,outpatient,,,23.55,17.66,,18.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.48,18.84,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204920,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-Uloric Oral Tablet 40MG,3204921,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Dexilant Delayed-Release Capsule 30MG,3204922,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Pravastatin Sodium Oral Tablet 20MG,3204923,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Progesterone Micronized  Pwd,3204925,CDM,637,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Toujeo Subcutaneous Solution 300U/1ML,3204926,CDM,250,RC,,,outpatient,,,367,275.25,,293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.68,293.6,
NF-Breo Ellipta Inhalation Powder,3204927,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-Ursodiol Oral Tablet 250MG,3204928,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Stiolto Respimat Inst Pack 28ACT,3204929,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Xarelto Oral Tablet 2.5MG,3204930,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Vraylar Oral Capsule 3MG,3204931,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Systane Ophthalmic Gel/Jelly 0.3%,3204932,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204934,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
DEXAMETHASONE 20MG/5ML(4MG/ML),3204936,CDM,637,RC,,,outpatient,,,2.35,1.76,,1.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.88,
NF-SEROquel Tablet 300MG,3204937,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Linzess Oral Capsule 145MCG,3204941,CDM,637,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Kristalose Oral Pwd for Susp 20GM/1Pk,3204943,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Cefprozil Oral Tablet 500MG,3204944,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Pseudo/guaiFENesin Tab ER 120MG-600MG,3204945,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Cefprozil Oral Tablet 500MG,3204946,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Pseudo/guaiFENesin Tab ER 120MG-600MG,3204947,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-CEFPROZIL ORAL TABLET 500MG,3204948,CDM,250,RC,,,outpatient,,,33.46,25.1,,26.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.46,26.77,
NF-PSEUDOEPHEDRINE/GUAIFENESIN 120MG-600,3204949,CDM,250,RC,,,outpatient,,,2.81,2.11,,2.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.13,2.25,
NF-ALEVE ARTHRITIS TAB 220MG,3204950,CDM,250,RC,,,outpatient,,,0.3,0.23,,0.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.12,0.24,
NF-ALEVE ORAL TABLET 220MG,3204951,CDM,250,RC,,,outpatient,,,0.47,0.35,,0.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.19,0.38,
NF-Aleve Liquid Capsule 220MG,3204953,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Valsartan/HCTZ Oral Tablet 80MG-12.5M,3204954,CDM,637,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Prazosin HCl Oral Capsule 1MG,3204955,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204956,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3204958,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3204959,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-NexAVAR Oral Tablet 200MG,3204961,CDM,250,RC,,,outpatient,,,690,517.5,,552,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,379.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,277.66,552,
NF-Entresto Oral Tablet 97MG-103MG,3204963,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Letrozole Oral Tablet 2.5MG,3204964,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Trileptal Oral Tablet 150MG,3204966,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Remeron Tablet 15MG,3204967,CDM,637,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
COVARYX HS,3204968,CDM,637,RC,,,outpatient,,,3.18,2.39,,2.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.28,2.54,
CHLOROPROCAINE  2% 20MG/ML 20mL VIAL,3204971,CDM,250,RC,,,outpatient,,,89.6,67.2,,71.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.06,71.68,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3204972,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-XIGDUO XR TAB ER 2.5MG-1000MG,3204973,CDM,250,RC,,,outpatient,,,36.44,27.33,,29.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.66,29.15,
NF-TRULICITY SUBQ SOLN 1.5MG/0.5ML,3204974,CDM,250,RC,,,outpatient,,,1621.04,1215.78,,1296.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.31,1296.83,
CEFDINIR 300 MG CAPSULE,3204975,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Anoro Ellipta Inhalation Powder,3204976,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Pataday Ophthalmic Solution 0.2%,3204977,CDM,250,RC,,,outpatient,,,312,234,,249.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.55,249.6,
NICOTINE LOZENGE 4 MG,3204978,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Trileptal Oral Tablet 150MG,3204979,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Trileptal Oral Tablet 150MG,3204980,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Methscopolamine Bromide Oral Tablet 5,3204982,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Proventil HFA Inhaler 0.09MG/Inh,3204983,CDM,637,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Flovent Diskus Inh/Neb Pwd 50MCG/1Act,3204984,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Trintellix Oral Tablet 5MG,3204985,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Geodon Capsule 60MG,3204986,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-Lyrica Oral Capsule 50MG,3204988,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
MELATONIN 5 MG,3204989,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Flecainide Acetate Tablet 100MG,3204990,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Letrozole Oral Tablet 2.5MG,3204991,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Ditropan XL Extended-Release Tablet 1,3204993,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Tresiba Subcutaneous Solution 200U/1M,3204994,CDM,250,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
NF-Ursodiol Oral Tablet 250MG,3204995,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Diclofenac Sodium Tablet 25MG,3205000,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Afinitor Oral Tablet 5MG,3205001,CDM,250,RC,,,outpatient,,,2490,1867.5,,1992,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1001.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1369.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1001.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1867.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1001.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1001.98,1992,
NF-Nuplazid Oral Capsule 34MG,3205003,CDM,250,RC,,,outpatient,,,449,336.75,,359.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,180.68,359.2,
NF-Linzess Oral Capsule 290MCG,3205004,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Theophylline Oral Tab ER 300MG,3205005,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Advair HFA 230/21 Inh Aer 230MCG-21MC,3205006,CDM,250,RC,,,outpatient,,,191,143.25,,152.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.86,152.8,
NF-Abilify Oral Tablet 2MG,3205007,CDM,250,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
NF-Alendronate Sodium Oral Tablet 10MG,3205008,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-ivermectin Oral Tablet 3MG,3205009,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Bi-Est (50:50)-Progest-Testost Kit,3205012,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-traMADol HCl Oral Cap ER 200MG,3205013,CDM,637,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-1ST TIER UNIFINE PENTIPS PLUS DEVICE,3205014,CDM,250,RC,,,outpatient,,,1.03,0.77,,0.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.57,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.41,0.82,
NF-BIOTIN CAP 5000MCG,3205015,CDM,250,RC,,,outpatient,,,0.27,0.2,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205016,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3205017,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-Omeprazole Oral Tablet DR 20MG,3205018,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Amaryl Tablet 1MG,3205020,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Admelog Injection Solution 100U/1ML,3205022,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-Methotrexate Oral Tablet 2.5MG,3205024,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
ALYACEN 1/35  28 DAY PK,3205025,CDM,637,RC,,,outpatient,,,31.03,23.27,,24.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.49,24.82,
NF-LaMICtal ODT Disintegrating Tablet 25,3205026,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-LaMICtal ODT Disintegrating Tablet 25,3205027,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3205030,CDM,250,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-Letrozole Oral Tablet 2.5MG,3205031,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Flecainide Acetate Tablet 100MG,3205032,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Jardiance Oral Tablet 25MG,3205033,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Stiolto Respimat Inst Pack 28ACT,3205034,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Allegra-D 12 Hour Oral Tab ER 60MG-12,3205035,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Osphena Oral Tablet 60MG,3205036,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Dexilant Delayed-Release Capsule 60MG,3205037,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Jardiance Oral Tablet 25MG,3205038,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-RisperDAL M-TAB Disintegrating Tab 4M,3205039,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Terazosin HCl Capsule 2MG,3205040,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Perforomist Inhalation Soln 20MCG/2ML,3205041,CDM,637,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3205042,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Abilify Tablet 20MG,3205043,CDM,250,RC,,,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,148.8,
NF-Adderall Oral Tablet 30MG,3205044,CDM,637,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Adderall Oral Tablet 30MG,3205045,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Anoro Ellipta Inhalation Powder,3205046,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Jentadueto Oral Tablet 2.5MG-1000MG,3205047,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Eszopiclone Oral Tablet 3MG,3205048,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Cefprozil Oral Tablet 500MG,3205049,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3205050,CDM,637,RC,,,outpatient,,,1621,1215.75,,1296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,652.29,1296.8,
NF-Multigen Plus Oral Tablet,3205052,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Adult Probiotic Oral Capsule,3205053,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Mexiletine HCl Capsule 150MG,3205056,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
Colcrys 0.6mg E340B,3205057,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Trintellix Oral Tablet 20MG,3205058,CDM,637,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Trintellix Oral Tablet 20MG,3205060,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205064,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3205065,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Lithium Carbonate Capsule 600MG,3205071,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Lithium Carbonate Capsule 600MG,3205073,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Linzess Oral Capsule 290MCG,3205075,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Trileptal Oral Tablet 150MG,3205076,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Doxepin HCl Oral Capsule 75MG,3205077,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Farxiga Oral Tablet 10MG,3205080,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Linzess Oral Capsule 290MCG,3205081,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-NovoLOG Mix 70/30 SubQ Susp 70U-30U/1,3205082,CDM,250,RC,,,outpatient,,,133,99.75,,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.52,106.4,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205083,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Myrbetriq Oral Tablet 25MG,3205084,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Tradjenta Oral Tablet 5MG,3205085,CDM,250,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-Pioglitazone Oral Tablet 15MG,3205086,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Levocetirizine Dihydrochloride Tab 5M,3205087,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-PIOGLITAZONE HCL ORAL TABLET 15MG,3205088,CDM,250,RC,,,outpatient,,,25.95,19.46,,20.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.44,20.76,
NF-Glimepiride Oral Tablet 1MG,3205089,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205090,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Amitriptyline HCl Oral Tablet 150MG,3205091,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Trelegy Ellipta Inhalation Powder,3205092,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Droxia Capsule 400MG,3205093,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Ferrous Sulfate Tablet 325mg,3205094,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Methotrexate Oral Tablet 2.5MG,3205099,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
DEBRIDMENT,6100049,CDM,521,RC,11042,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,990.21,
NF-Wellbutrin SR 12 Hr Tab ER 150MG,3205102,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Bacmin Oral Tablet,3205103,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
GLIMEPIRIDE 1 MG,3205104,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-NexIUM Capsule 40MG,3205105,CDM,637,RC,,,outpatient,,,53,39.75,,42.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.33,42.4,
NF-Oxybutynin Oral Tab ER 10MG,3205106,CDM,637,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Soma Tablet 350MG,3205110,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Humira Subcutaneous Solution 20MG/0.2,3205111,CDM,250,RC,,,outpatient,,,11486,8614.5,,9188.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6317.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9188.8,
NF-Senokot S Tablet,3205112,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Cefprozil Oral Tablet 500MG,3205113,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Fenofibrate Oral Tablet 54MG,3205114,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Jardiance Oral Tablet 25MG,3205115,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Omeprazole Delayed Release Capsule 40,3205116,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-dilTIAZem Oral Cap ER 240MG,3205117,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Glucocard Shine Test Strips Device,3205119,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Theophylline Oral Tab ER 300MG,3205120,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Oxybutynin Oral Tab ER 10MG,3205122,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Lyrica Oral Capsule 150MG,3205123,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205124,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Chantix Continuing Month Box,3205125,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Prenatal 19 Oral Tablet,3205126,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Chantix Continuing Month Box,3205127,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Prenatal 19 Oral Tablet,3205128,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205129,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Jalyn Oral Capsule 0.5MG-0.4MG,3205130,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Cardizem CD Extended Release Cap 300M,3205131,CDM,250,RC,,,outpatient,,,247,185.25,,197.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.39,197.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3205132,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Folbee Tablet 1MG-2.5MG-25MG,3205134,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-SEROquel XR Oral Tab ER 400MG,3205136,CDM,250,RC,,,outpatient,,,111,83.25,,88.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.67,88.8,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205137,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Ketotifen Fumarate Ophth Solution 0.0,3205138,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Lisinopril Tablet 2.5mg,3205139,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Uloric Oral Tablet 40MG,3205140,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-CORTISONE ACETATE TAB 25MG,3205141,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Anoro Ellipta Inhalation Powder,3205142,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3205143,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Jentadueto Oral Tablet 2.5MG-1000MG,3205144,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-TIAGABINE HYDROCHLORIDE ORAL TABLET 1,3205145,CDM,250,RC,,,outpatient,,,55.79,41.84,,44.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.45,44.63,
NF-ENTRESTO ORAL TABLET 97MG-103MG,3205146,CDM,250,RC,,,outpatient,,,37.67,28.25,,30.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.16,30.14,
NF-Tradjenta Oral Tablet 5MG,3205147,CDM,250,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-Flecainide Acetate Tablet 100MG,3205149,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Namenda XROral Capsule ER 28MG,3205150,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Tresiba Subcutaneous Solution 200U/1M,3205151,CDM,250,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
NF-Proair HFA Inh Susp 0.09MG/1Act,3205153,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-diazePAM Rectal Delivery System Kit,3205158,CDM,250,RC,,,outpatient,,,1135,851.25,,908,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,456.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,567.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,567.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,567.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,567.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,908,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,456.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,908,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,851.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,908,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,908,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,456.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,908,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,456.72,908,
NF-Propranolol Hydrochloride Cap ER 120M,3205159,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Vimpat Oral Tablet 100MG,3205160,CDM,250,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Trintellix Oral Tablet 5MG,3205161,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Omega-3-Acid Ethyl Esters Liq Cap 1GM,3205162,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Jardiance Oral Tablet 25MG,3205163,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-rOPINIRole Hydrochloride Tablet 3MG,3205164,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-hydroCHLOROthiazide Oral Tablet 12.5M,3205165,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Descovy Oral Tablet 200MG-25MG,3205167,CDM,250,RC,,,outpatient,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.62,208,
NF-Tivicay Oral Tablet 50MG,3205168,CDM,250,RC,,,outpatient,,,257,192.75,,205.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,103.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,103.42,205.6,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205169,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3205171,CDM,637,RC,,,outpatient,,,476,357,,380.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.54,380.8,
NF-Sodium Chloride Ophth Solution 5%,3205172,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Bactroban Ointment 2%,3205173,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
SOD. POLYSTYRENE FOR SUSPENSION 15 G,3205175,CDM,637,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-PreserVision Lutein Lquid Filled Caps,3205176,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Invokana Oral Tablet 300MG,3205178,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205179,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
LETROZOLE 2.5 MG TABLET,3205180,CDM,637,RC,,,outpatient,,,19.6,14.7,,15.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.89,15.68,
NF-Pulmicort Flex Inh/Neb Pwd 180MCG/1AC,3205182,CDM,250,RC,,,outpatient,,,695,521.25,,556,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,347.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,382.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,279.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,521.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,279.67,556,
NF-Diclofenac Sodium Topical Solution 1.,3205183,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Xigduo XR Oral Tablet ER 10MG-1000MG,3205185,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Mexiletine HCl Capsule 150MG,3205186,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Jardiance Oral Tablet 25MG,3205187,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Jardiance Oral Tablet 25MG,3205188,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Trileptal Oral Tablet 150MG,3205189,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
OTEZLA 30 MG TABLET E340B,3205190,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-TROKENDI XR CAP ER 100MG,3205191,CDM,250,RC,,,outpatient,,,109.54,82.16,,87.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.08,87.63,
NF-Breo Ellipta Inhalation Powder,3205192,CDM,637,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Remeron Tablet 15MG,3205193,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Xarelto Oral Tablet 20MG,3205194,CDM,250,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
NF-Anoro Ellipta Inhalation Powder,3205195,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205196,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Proair HFA Inh Susp 0.09MG/1Act,3205197,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Soma Tablet 350MG,3205198,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Pepcid Oral Tablet 40MG,3205199,CDM,637,RC,,,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,65.6,
NF-Gabapentin Oral Tablet 400MG,3205204,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Pyridium Oral Tablet 200MG,3205205,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Farxiga Oral Tablet 5MG,3205206,CDM,637,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3205207,CDM,637,RC,,,outpatient,,,1685,1263.75,,1348,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,926.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,678.04,1348,
NF-Farxiga Oral Tablet 5MG,3205208,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3205209,CDM,250,RC,,,outpatient,,,1685,1263.75,,1348,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,842.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,926.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1263.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,678.04,1348,
NF-Cryselle 28 Tablet,3205210,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Vitamin D Oral Tablet 5000IU,3205211,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-L-CARNITINE TABLET 500MG,3205212,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205213,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-SEROquel Oral Tablet 400MG,3205214,CDM,637,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
NF-Imitrex Oral Tablet 25MG,3205215,CDM,637,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Trelegy Ellipta Inhalation Powder,3205216,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-PRAZOSIN HCL     CAP  2MG,3205217,CDM,250,RC,,,outpatient,,,4.71,3.53,,3.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.9,3.77,
NF-ZONISAMIDE CAP 25MG,3205218,CDM,250,RC,,,outpatient,,,1.48,1.11,,1.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.18,
NF-carBAMazepine Chewable Tablet 100MG,3205220,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-PreserVision Lutein Lquid Filled Caps,3205221,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Depo-Estradiol IM Oil 5MG/1ML,3205222,CDM,250,RC,,,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
NF-Depo-Provera IM Susp 150MG/1ML,3205223,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Depo-Provera IM Susp 150MG/1ML,3205224,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Depo-Provera Contrace Injection 150MG,3205225,CDM,637,RC,,,outpatient,,,388,291,,310.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.13,310.4,
NF-Jardiance Oral Tablet 25MG,3205226,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Depo-Provera Contrace Injection 150MG,3205227,CDM,637,RC,,,outpatient,,,388,291,,310.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.13,310.4,
NF-Sertraline Hydrochloride Oral Tablet,3205229,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Methenamine Hippurate Oral Tablet 1GM,3205230,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Viberzi Oral Tablet 100MG,3205231,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Depo-Provera IM Suspension 150MG/1ML,3205232,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Onglyza Oral Tablet 5MG,3205233,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Linzess Oral Capsule 145MCG,3205234,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Toujeo Subcutaneous Solution 300U/1ML,3205235,CDM,250,RC,,,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,306.4,
NF-Farxiga Oral Tablet 10MG,3205236,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Megestrol Acetate Tablet 20MG,3205238,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Hydrocortisone Oral Tablet 5MG,3205239,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205240,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Myrbetriq Oral Tablet 25MG,3205241,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Rexulti Oral Tablet 4MG,3205242,CDM,250,RC,,,outpatient,,,172,129,,137.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.21,137.6,
NF-Trulance Oral Tablet 3MG,3205243,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-glyBURIDE Tablet 2.5MG,3205244,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-K-Phos Original Tablet 500MG,3205245,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Depo-Provera IM Suspension 150MG/1ML,3205246,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
GLIMEPIRIDE 4 MG  E340B,3205248,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
ISOSORBIDE MON ER 30 MG  E340B,3205249,CDM,637,RC,,,outpatient,,,0.03,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
JANUVIA 100MG E340B,3205250,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
OMEPRAZOLE DR 40 MG E340B,3205252,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
REPAGLINIDE 2 MG E340B,3205254,CDM,637,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
TOPROL XL 50 MG  E340B,3205255,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
INDOMETHACIN 50  MG CAP,3205256,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
VISINE AC DROPS,3205257,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Depo-Provera Injection 150MG/ML,3205259,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Rivastigmine Tartrate Oral Capsule 3M,3205260,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Rivastigmine Tartrate Oral Capsule 3M,3205261,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Depo-Provera IM Susp 150MG/1ML,3205262,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Depo-Provera IM Suspension 150MG/1ML,3205263,CDM,637,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera IM Susp 150MG/1ML,3205264,CDM,637,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Dronabinol Oral Liq Cap 5MG,3205265,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-dutasteride-tamsulosin HCl 0.5MG-0.4M,3205266,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Gilotrif Oral Tablet 20MG,3205267,CDM,250,RC,,,outpatient,,,1303,977.25,,1042.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,651.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,651.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,651.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,651.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,716.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,524.33,1042.4,
NF-Depo-Provera IM Susp 150MG/1ML,3205268,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
METOPROLOL SUCC. E.R. 25MG E340B,3205269,CDM,637,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-Linzess Oral Capsule 145MCG,3205270,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Namenda XROral Capsule ER 28MG,3205271,CDM,637,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Namenda XROral Capsule ER 28MG,3205272,CDM,637,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Namenda XROral Capsule ER 28MG,3205273,CDM,637,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Namenda XROral Capsule ER 28MG,3205274,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
ATACAND 16 MG E340B,3205275,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
ESTRADIOL 1 MG TAB  E340B,3205276,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
LEVOTHYROXINE 50 MCG E340B,3205278,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
PRAVASTATIN 40 MG E340B,3205280,CDM,637,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-Creon Oral Delayed Release Capsule,3205281,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Vascepa Oral Liquid Filled Cap 1GM,3205282,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
CLONAZEPAM 2 MG,3205283,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Victoza Subcutaneous Solution 6MG/1ML,3205284,CDM,250,RC,,,outpatient,,,454,340.5,,363.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,227,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,227,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,227,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,227,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,249.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,182.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,182.69,363.2,
NF-Geritol Complete Tablet,3205286,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Phillips' Colon Health Oral Capsule,3205287,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-L-Carnitine Tablet 500MG,3205288,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Imitrex Oral Tablet 25MG,3205289,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Movantik Oral Tablet 12.5MG,3205290,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Vraylar Oral Capsule 3MG,3205292,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205293,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
FLUOXETINE 20 MG CAPSULE E340B,3205294,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Letrozole Oral Tablet 2.5MG,3205295,CDM,637,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Flecainide Acetate Tablet 100MG,3205296,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Leflunomide Oral Tablet 20MG,3205297,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Letrozole Oral Tablet 2.5MG,3205298,CDM,637,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Flecainide Acetate Tablet 100MG,3205299,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Leflunomide Oral Tablet 20MG,3205300,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Jentadueto Oral Tablet 2.5MG-1000MG,3205301,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Depo-Provera Contrace Injection 150MG,3205306,CDM,250,RC,,,outpatient,,,388,291,,310.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.13,310.4,
NF-Haldol Decanoate IM Oil 100MG/1ML,3205308,CDM,250,RC,,,outpatient,,,737,552.75,,589.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,296.57,589.6,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205310,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Namenda XR Oral Capsule ER 7MG,3205311,CDM,637,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Depo-Provera Injection 150MG/ML,3205312,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
OXYCONTIN CR 20 MG TABLET,3205315,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Depo-Provera Injection 150MG/ML,3205316,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera Injection 150MG/ML,3205317,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Invokana Oral Tablet 300MG,3205322,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
TRINTELLIX 10 MG E340B,3205324,CDM,637,RC,,,outpatient,,,2.35,1.76,,1.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.88,
NF-Linzess Oral Capsule 145MCG,3205326,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Linzess Oral Capsule 72MCG,3205327,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Depo-Provera Injection 150MG/ML,3205330,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Albuterol Sulfate Inh Susp 0.09MG/1Ac,3205331,CDM,637,RC,,,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,46.4,
APTIOM 200 MG E340B,3205332,CDM,637,RC,,,outpatient,,,8.14,6.11,,6.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.28,6.51,
AMITRIPTYLINE 50 MG E340B,3205333,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
DULOXETINE DR 60 MG E340B,3205334,CDM,637,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-Depo-Provera IM Suspension 150MG/1ML,3205335,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
PERMETHRIN CREAM 5% 60G E340B,3205336,CDM,637,RC,,,outpatient,,,7.03,5.27,,5.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.83,5.62,
TRIAMCINOLONE ACE CR  0.1% 80 G  E340B,3205337,CDM,637,RC,,,outpatient,,,0.77,0.58,,0.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.31,0.62,
JARDIANCE 25 MG E340B,3205338,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
TRADJENTA 5 MG E340B,3205339,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Trulance Oral Tablet 3MG,3205340,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-12-HOUR NASAL SPRAY 0.05%,3205341,CDM,250,RC,,,outpatient,,,0.11,0.08,,0.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.04,0.09,
NF-Xtandi Oral Liquid Filled Capsule 40M,3205342,CDM,250,RC,,,outpatient,,,427,320.25,,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,234.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,171.82,341.6,
NF-Suboxone Sublingual Film 8MG-2MG,3205343,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-LUBRICANT EYE DROPS OPHTH SOLN 0.25%,3205344,CDM,637,RC,,,outpatient,,,1.17,0.88,,0.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.47,0.94,
NF-LUBRICANT EYE DROPS OPHTH SOLN 0.5%,3205345,CDM,250,RC,,,outpatient,,,1.48,1.11,,1.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.18,
NF-Restasis Ophthalmic Emulsion 0.05%,3205347,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Lubricant Eye Drops Ophth Soln 0.5%,3205348,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Trintellix Oral Tablet 20MG,3205349,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Breo Ellipta Inhalation Powder,3205351,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Omeprazole-Sodium Bicarbonate 40-1100,3205353,CDM,250,RC,,,outpatient,,,387,290.25,,309.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,290.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.73,309.6,
NF-Depo-Provera Contrace Injection 150MG,3205354,CDM,250,RC,,,outpatient,,,388,291,,310.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.13,310.4,
NF-Vimpat Oral Tablet 100MG,3205355,CDM,250,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Bi-Est (50:50)-Progest-Testost Kit,3205357,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Triamterene/HCTZ Capsule 37.5-25MG,3205358,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Ditropan XL Extended-Release Tablet 1,3205359,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Humira SubQ Kit 40MG/0.8ML,3205360,CDM,250,RC,,,outpatient,,,11486,8614.5,,9188.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6317.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9188.8,
LYRICA 50 MG  E340B,3205362,CDM,637,RC,,,outpatient,,,0.07,0.05,,0.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.03,0.06,
NF-Dexilant Delayed-Release Capsule 60MG,3205363,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Azor Oral Tablet 5MG-40MG,3205364,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Zarxio Injection Solution 300MCG/0.5M,3205365,CDM,250,RC,,,outpatient,,,2447,1835.25,,1957.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1345.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,984.67,1957.6,
NF-Jentadueto Oral Tablet 2.5MG-1000MG,3205366,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Vitamin D Oral Capsule 50000IU,3205368,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Depo-Provera Contrace Injection 150MG,3205371,CDM,250,RC,,,outpatient,,,388,291,,310.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.13,310.4,
NF-Desmopressin Nasal Spray 0.1MG/Actuat,3205372,CDM,250,RC,,,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
NF-Depo-Provera IM Suspension 150MG/1ML,3205373,CDM,250,RC,,,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.47,356.8,
NF-Trintellix Oral Tablet 5MG,3205375,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Embeda Capsule ER 20MG-0.8MG,3205376,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Trulance Oral Tablet 3MG,3205377,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Vyvanse Oral Capsule 30MG,3205378,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Depo-Provera Contrace Injection 150MG,3205379,CDM,250,RC,,,outpatient,,,388,291,,310.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.13,310.4,
NF-DEPO-Medrol Injection 40MG/ML,3205380,CDM,637,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Depo-Provera IM Susp 150MG/1ML,3205381,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Probenecid/Colchicine Tab 500MG-0.5MG,3205382,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Probenecid/Colchicine Tablet,3205383,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
LEVOTHYROXINE 0.112 MG E340B,3205384,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
TRILEPTAL 600 MG E340B,3205385,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Depo-Provera Injection 150MG/ML,3205386,CDM,250,RC,,,outpatient,,,887,665.25,,709.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,356.93,709.6,
NF-busPIRone Oral Tablet 10MG,3205387,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3205388,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Theophylline Oral Tab ER 300MG,3205389,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Shingrix Intramuscular Susp 50MCG/0.5,3205390,CDM,250,RC,,,outpatient,,,640,480,,512,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,257.54,512,
NF-DEXILANT CAP DR 60MG,3205391,CDM,250,RC,,,outpatient,,,16.21,12.16,,12.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.52,12.97,
NF-Shingrix Intramuscular Susp 50MCG/0.5,3205392,CDM,250,RC,,,outpatient,,,640,480,,512,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,257.54,512,
LEVOTHYROXINE 0.15 MG E340B,3205393,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
PREMPHASE TAB COMBO (28) E340B,3205394,CDM,637,RC,,,outpatient,,,0.27,0.2,,0.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.11,0.22,
NF-Depo-Provera Injection 150MG/ML,3205395,CDM,637,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera IM Susp 150MG/1ML,3205396,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Trelegy Ellipta Inhalation Powder,3205397,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Proair HFA Inh Susp 0.09MG/1Act,3205399,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Depo-Provera IM Susp 150MG/1ML,3205400,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Jardiance Oral Tablet 25MG,3205402,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
PAROMOMYCIN SULFATE 250 MG CAPSULE,3205403,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Depo-Provera IM Susp 150MG/1ML,3205404,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-raNITIdine Oral Tablet 300MG,3205405,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Depo-Provera IM Susp 150MG/1ML,3205406,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Depo-Provera IM Susp 150MG/1ML,3205407,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Depo-Provera IM Susp 150MG/1ML,3205408,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Haldol Decanoate IM Oil 100MG/1ML,3205409,CDM,250,RC,,,outpatient,,,737,552.75,,589.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,296.57,589.6,
NF-Bicillin C-R IM Susp 600000U-600000U/,3205410,CDM,637,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Bicillin L-A IM Suspension 600000U/1M,3205411,CDM,250,RC,,,outpatient,,,349,261.75,,279.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.44,279.2,
NF-Namenda XR Oral Capsule ER 14MG,3205412,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Coenzyme Q-10 Tablet 50MG,3205413,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3205414,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Creon Oral Delayed Release Capsule,3205415,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Vascepa Oral Liquid Filled Cap 1GM,3205417,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Creon Oral Delayed Release Capsule,3205418,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Repatha Subcutaneous Solution 140MG/1,3205419,CDM,250,RC,,,outpatient,,,2480,1860,,1984,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1364,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,997.95,1984,
NF-metOLazone Oral Tablet 2.5MG,3205420,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Glyxambi Oral Tablet 10MG-5MG,3205421,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Depo-Provera IM Susp 150MG/1ML,3205422,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3205423,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
LOVENOX 40 MG  E340B,3205424,CDM,637,RC,,,outpatient,,,1.72,1.29,,1.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.69,1.38,
NF-Bicillin L-A IM Suspension 600000U/1M,3205425,CDM,637,RC,,,outpatient,,,307,230.25,,245.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.54,245.6,
"NF-Bicillin L-A Injection 600,000U/ML",3205426,CDM,250,RC,,,outpatient,,,111,83.25,,88.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.67,88.8,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205427,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205428,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205430,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205431,CDM,637,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Lupron Depot 3 Month Pwd for Susp 11.,3205432,CDM,250,RC,,,outpatient,,,17321,12990.75,,13856.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6969.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8660.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8660.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8660.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8660.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9526.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12990.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12990.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12990.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12990.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6969.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6969.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12990.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6969.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,13856.8,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205433,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Pravastatin Sodium Oral Tablet 40MG,3205434,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Pravastatin Sodium Oral Tablet 40MG,3205435,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Haldol Decanoate IM Oil 100MG/1ML,3205436,CDM,250,RC,,,outpatient,,,737,552.75,,589.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,296.57,589.6,
NF-Levobunolol HCl Ophth Solution 0.5%,3205437,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3205438,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
TOPIRAMATE 100 MG E340B,3205439,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
CEFPROZIL 125MG/5ML SUSP,3205440,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Bicillin C-R IM Susp 600000U-600000U/,3205441,CDM,250,RC,,,outpatient,,,254,190.5,,203.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,102.21,203.2,
NF-Depo-Provera IM Susp 150MG/1ML,3205442,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Entresto Oral Tablet 49MG-51MG,3205443,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Jentadueto Oral Tablet 2.5MG-1000MG,3205444,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Zarxio Injection Solution 300MCG/0.5M,3205446,CDM,250,RC,,,outpatient,,,2447,1835.25,,1957.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1345.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1835.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,984.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1957.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,984.67,1957.6,
NF-Vimpat Oral Tablet 200MG,3205447,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-TYLENOL-CODEINE #4 TAB 300MG-60MG,3205449,CDM,250,RC,,,outpatient,,,4.85,3.64,,3.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.67,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.95,3.88,
NF-PRAZOSIN HCL     CAP  2MG,3205450,CDM,250,RC,,,outpatient,,,4.71,3.53,,3.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.9,3.77,
NF-SIMBRINZA OPHTH SUSP 0.2%-1%,3205451,CDM,250,RC,,,outpatient,,,90.32,67.74,,72.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.34,72.26,
NF-dilTIAZem CD Capsule ER 300MG,3205452,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-Uloric Oral Tablet 40MG,3205453,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Dexilant Delayed-Release Capsule 60MG,3205454,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Aciphex Enteric Coated Tablet 20MG,3205455,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Corlanor Oral Tablet 5MG,3205456,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Haldol Decanoate IM Oil 50MG/1ML,3205457,CDM,250,RC,,,outpatient,,,386,289.5,,308.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.33,308.8,
NF-Depo-Provera Injection 150MG/ML,3205458,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205459,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205460,CDM,637,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Vraylar Oral Capsule 3MG,3205461,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Depo-Provera IM Suspension 150MG/1ML,3205462,CDM,250,RC,,,outpatient,,,887,665.25,,709.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,356.93,709.6,
NF-Amitriptyline HCl Oral Tablet 150MG,3205463,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Aimovig 70MG SubQ Solution,3205464,CDM,250,RC,,,outpatient,,,2553,1914.75,,2042.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1027.33,2042.4,
NF-medroxyPROGESTERone Acetate 150MG/1ML,3205465,CDM,637,RC,,,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.08,159.2,
NF-medroxyPROGESTERone  IM Susp 150MG/1M,3205466,CDM,250,RC,,,outpatient,,,362,271.5,,289.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.67,289.6,
NF-Zestril Oral Tablet 40MG,3205467,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-Alclometasone Dipropionate  Cream 0.0,3205468,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Jardiance Oral Tablet 10MG,3205470,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Namenda XR Oral Capsule ER 14MG,3205471,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-OXcarbazepine Oral Tablet 150MG,3205472,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Cosopt PF Ophthalmic Solution 2%-0.5%,3205473,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-LaMICtal Tablet 150MG,3205475,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-OXcarbazepine Oral Tablet 150MG,3205476,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-LaMICtal Tablet 150MG,3205478,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-OXcarbazepine Oral Tablet 150MG,3205479,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-LaMICtal Tablet 150MG,3205481,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-VYTORIN ORAL TABLET 10MG-40MG,3205482,CDM,250,RC,,,outpatient,,,50.57,37.93,,40.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.35,40.46,
NF-Vytorin Oral Tablet 10MG-40MG,3205483,CDM,637,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
NF-HYDROcodone-acetaminophen 7.5MG-300MG,3205484,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-CARDIZEM CD 24 HR CAP ER 360MG,3205486,CDM,250,RC,,,outpatient,,,360.99,270.74,,288.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.26,288.79,
NF-DILTIAZEM HCL 24 HR CAP ER 360MG,3205487,CDM,250,RC,,,outpatient,,,9.58,7.19,,7.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.85,7.66,
NF-Depo-Provera IM Suspension 150MG/1ML,3205488,CDM,250,RC,,,outpatient,,,846,634.5,,676.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,340.43,676.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205490,CDM,250,RC,,,outpatient,,,887,665.25,,709.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,356.93,709.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3205493,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Bicillin L-A IM Suspension 600000U/1M,3205494,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Bicillin L-A IM Suspension 600000U/1M,3205495,CDM,637,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Viibryd Oral Tablet 10MG,3205496,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Depo-Provera IM Susp 150MG/1ML,3205497,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Adderall Oral Tablet 20MG,3205499,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-OXcarbazepine Oral Tablet 150MG,3205500,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-LaMICtal Tablet 150MG,3205501,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Nystatin Powder,3205503,CDM,637,RC,,,outpatient,,,5140,3855,,4112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2068.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2570,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2570,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2570,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2570,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2827,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2068.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2068.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2068.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2068.34,4112,
NF-Jardiance Oral Tablet 10MG,3205504,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-MORPHINE SULFATE ORAL SOLUTION 20MG/1,3205505,CDM,250,RC,,,outpatient,,,2.77,2.08,,2.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.11,2.22,
NF-LORAZEPAM INTENSOL SOLN 2MG/1ML,3205506,CDM,250,RC,,,outpatient,,,16.42,12.32,,13.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.61,13.14,
NF-Tresiba Subcutaneous Solution 100U/1M,3205507,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Anoro Ellipta Inhalation Powder,3205513,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Ketorolac Tromethamine Ophth Soln 0.4,3205514,CDM,250,RC,,,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
NF-Ofloxacin Ophthalmic Solution 0.3%,3205515,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Haldol Decanoate IM Oil 100MG/1ML,3205517,CDM,250,RC,,,outpatient,,,737,552.75,,589.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,296.57,589.6,
NF-Triamcinolone Acetonide Cream 0.1%,3205518,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-glipiZIDE-metFORMIN Tab 5MG-500MG,3205519,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Triamcinolone Acetonide Cream 0.1%,3205520,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-OXcarbazepine Oral Tablet 150MG,3205521,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-LaMICtal Tablet 150MG,3205523,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Drisdol Oral LiquidFilledCapsule 5000,3205524,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Trelegy Ellipta Inhalation Powder,3205526,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Trintellix Oral Tablet 20MG,3205527,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
REMOVAL SKIN TAGS UP TO 15,6100053,CDM,521,RC,11200,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,266.88,
NF-Humira Subcutaneous Solution 40MG/0.8,3205530,CDM,250,RC,,,outpatient,,,11486,8614.5,,9188.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5743,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6317.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8614.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4621.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9188.8,
NF-Toujeo Subcutaneous Solution 300U/1ML,3205531,CDM,250,RC,,,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,306.4,
NF-guanFACINE HCl Oral Tab ER 2MG,3205533,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-NovoLIN 70/30 SubQ Susp 70U-30U/1ML,3205534,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205535,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205538,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Trelegy Ellipta Inhalation Powder,3205539,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Linzess Oral Capsule 145MCG,3205541,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Jardiance Oral Tablet 25MG,3205542,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Myrbetriq Oral Tablet 50MG,3205543,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Tikosyn Oral Capsule 250MCG,3205544,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Invokana Oral Tablet 300MG,3205545,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Invokana Oral Tablet 300MG,3205546,CDM,637,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-carBAMazepine Oral Cap ER 200MG,3205547,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
SHAVING SKIN LESION <0.5 CM,6100054,CDM,521,RC,11300,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,551.37,
NF-OXcarbazepine Oral Tablet 150MG,3205550,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205551,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-metFORMIN Hydrochloride Tab ER 1000MG,3205552,CDM,250,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
NF-Vimpat Oral Tablet 50MG,3205553,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205554,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205555,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Anoro Ellipta Inhalation Powder,3205556,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205557,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205558,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205559,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Dexilant Delayed-Release Capsule 30MG,3205560,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205561,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Promethazine HCl Tablet 25MG,3205562,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Senokot S Oral Tablet 50MG-8.6MG,3205563,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205564,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Jardiance Oral Tablet 25MG,3205565,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Rozerem Oral Tablet 8MG,3205567,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Letrozole Oral Tablet 2.5MG,3205568,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Flecainide Acetate Tablet 100MG,3205569,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Leflunomide Oral Tablet 20MG,3205570,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Leflunomide Oral Tablet 20MG,3205571,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
TRINTELLIX 20 MG E340B,3205572,CDM,637,RC,,,outpatient,,,2.35,1.76,,1.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.88,
NF-Depo-Provera Injection 150MG/ML,3205573,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Aimovig 70MG SubQ Solution,3205574,CDM,250,RC,,,outpatient,,,2553,1914.75,,2042.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1276.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1914.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1027.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1027.33,2042.4,
NF-Methotrexate Oral Tablet 2.5MG,3205575,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Tresiba Subcutaneous Solution 100U/1M,3205576,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Cellcept Tablet 500MG,3205577,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-LOVAZA ORAL LIQUID FILLED CAPSULE 1GM,3205578,CDM,250,RC,,,outpatient,,,11.05,8.29,,8.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.45,8.84,
NF-Trintellix Oral Tablet 20MG,3205579,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205580,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2018-2019 IM Susp,3205581,CDM,637,RC,,,outpatient,,,415,311.25,,332,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,167,332,
NF-Uloric Oral Tablet 40MG,3205582,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205584,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205585,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205586,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205587,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Toujeo Subcutaneous Solution 300U/1ML,3205588,CDM,250,RC,,,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,306.4,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205589,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Durezol Ophthalmic Emulsion 0.05%,3205591,CDM,250,RC,,,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,132,
NF-Dantrolene Sodium Oral Capsule 50MG,3205592,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205597,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Linzess Oral Capsule 72MCG,3205601,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Uloric Oral Tablet 40MG,3205605,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Depo-Provera IM Suspension 150MG/1ML,3205611,CDM,637,RC,,,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.47,356.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205612,CDM,250,RC,,,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.47,356.8,
NF-Letrozole Oral Tablet 2.5MG,3205613,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Flecainide Acetate Tablet 100MG,3205614,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Leflunomide Oral Tablet 20MG,3205615,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Flecainide Acetate Tablet 100MG,3205616,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Restasis Ophthalmic Emulsion 0.05%,3205617,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205618,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205621,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Azilect Oral Tablet 1MG,3205622,CDM,250,RC,,,outpatient,,,115,86.25,,92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.28,92,
NF-Depo-Provera IM Suspension 150MG/1ML,3205624,CDM,250,RC,,,outpatient,,,887,665.25,,709.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,356.93,709.6,
NF-Tradjenta Oral Tablet 5MG,3205625,CDM,250,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205626,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205627,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205628,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205629,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Uloric Oral Tablet 40MG,3205630,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205631,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Cartia XT Oral 24 Hr Cap ER 300MG,3205632,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Steglujan Oral Tablet 15MG-100MG,3205633,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Brimonidine Tartrate Ophth Soln 0.15%,3205634,CDM,250,RC,,,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.91,103.2,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205635,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205637,CDM,250,RC,,,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,223,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.47,356.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205638,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205639,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205641,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205642,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205644,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Linzess Oral Capsule 145MCG,3205645,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205646,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205647,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2018-2019 IM Susp,3205648,CDM,637,RC,,,outpatient,,,415,311.25,,332,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,167,332,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205649,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Symbicort Inh Aer Liq 160MCG-4.5MCG,3205651,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Nuedexta Oral Capsule 20MG-10MG,3205652,CDM,250,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205653,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205654,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205655,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Vraylar Oral Capsule 3MG,3205656,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205657,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-medroxyPROGESTERone  IM Susp 150MG/1M,3205658,CDM,250,RC,,,outpatient,,,361,270.75,,288.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.27,288.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205659,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-medroxyPROGESTERone  IM Susp 150MG/1M,3205660,CDM,250,RC,,,outpatient,,,362,271.5,,289.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.67,289.6,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205661,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
ZIM'S MAX FREEZE GEL,3205663,CDM,637,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
NF-Tikosyn Oral Capsule 250MCG,3205664,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205665,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205666,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205667,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
SHAVING LESION 0.6-1.0CM,6100059,CDM,521,RC,11311,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,266.87,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205669,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205670,CDM,637,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Tradjenta Oral Tablet 5MG,3205671,CDM,250,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-TEGretol-XR Tablet 100MG,3205673,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Midodrine HCl Tablet 5MG,3205675,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Methadone HCl Tablet 10MG,3205676,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205677,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-Trelegy Ellipta Inhalation Powder,3205678,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
CEFPROZIL 500 MG,3205679,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Prazosin Oral Capsule 2MG,3205681,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Bevespi Aerosphere Inh 4.8MCG-9MCG/1A,3205682,CDM,250,RC,,,outpatient,,,151,113.25,,120.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.76,120.8,
NF-Depo-Provera IM Suspension 150MG/1ML,3205683,CDM,250,RC,,,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NF-Rozerem Oral Tablet 8MG,3205684,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Entresto Oral Tablet 49MG-51MG,3205685,CDM,637,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Jentadueto Oral Tablet 2.5MG-1000MG,3205686,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Parnate Oral Tablet 10MG,3205688,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-ATIVAN INJ SOLN 2MG/1ML,3205689,CDM,250,RC,,,outpatient,,,7.13,5.35,,5.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.87,5.7,
NF-MORPHINE SULFATE ORAL SOLUTION 20MG/1,3205690,CDM,250,RC,,,outpatient,,,3.11,2.33,,2.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.25,2.49,
NF-Trelegy Ellipta Inhalation Powder,3205691,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Orphenadrine Oral Tab ER 100MG,3205692,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205694,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
DOBUTAMINE 500MG/250ML D5W,3205695,CDM,636,RC,,,both,,,41.93,31.45,,33.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.87,41.93,
NF-Fluzone High-Dose 2019-2020 IM Susp,3205696,CDM,250,RC,,,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.45,348.8,
NF-glipiZIDE Tablet 10MG,3205697,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Fenofibrate Oral Tablet 160MG,3205698,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Tradjenta Oral Tablet 5MG,3205699,CDM,250,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-NovoLOG Injection 100U/ML,3205700,CDM,250,RC,,,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
NF-Tikosyn Oral Capsule 250MCG,3205701,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-ALEVE PM ORAL TABLET 220MG-25MG,3205702,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Ingrezza Oral Capsule 40MG,3205703,CDM,250,RC,,,outpatient,,,885,663.75,,708,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,486.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,356.12,708,
NF-EXFORGE HCT ORAL TABLET 10MG-320MG-25,3205704,CDM,250,RC,,,outpatient,,,21.06,15.8,,16.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,16.85,
NF-Linzess Oral Capsule 145MCG,3205705,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Lunesta Tablet 3MG,3205706,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
XARELTO 2.5 MG,3205707,CDM,637,RC,,,outpatient,,,10.75,8.06,,8.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.91,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.33,8.6,
XARELTO 20 MG,3205708,CDM,637,RC,,,outpatient,,,21.5,16.13,,17.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.65,17.2,
NF-Tacrolimus Oral Capsule 1MG,3205709,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-valGANciclovir HCl Oral Tablet 450MG,3205711,CDM,250,RC,,,outpatient,,,238,178.5,,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,95.77,190.4,
NF-Nitroglycerin Sublingual Tablet 0.4MG,3205712,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Verapamil Hydrochloride Oral Tab 120M,3205713,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Farxiga Oral Tablet 10MG,3205714,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Zenpep Oral Delayed Release Capsule,3205715,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Cytomel Tablet 25MCG,3205716,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Esomeprazole Magnesium Oral Cap DR 40,3205717,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Anoro Ellipta Inhalation Powder,3205718,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
CEFPROZIL SUSP. 250MG/5ML   50 ML,3205719,CDM,637,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Amitriptyline Oral Tablet 50MG,3205720,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Cardura Tablet 1MG,3205721,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Omeprazole Oral Tablet DR 20MG,3205722,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Omeprazole Oral Tablet DR 20MG,3205724,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Amitriptyline Oral Tablet 50MG,3205726,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Shingrix Intramuscular Susp 50MCG/0.5,3205727,CDM,250,RC,,,outpatient,,,640,480,,512,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,257.54,512,
NF-Xtandi Oral Liquid Filled Capsule 40M,3205728,CDM,250,RC,,,outpatient,,,427,320.25,,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,234.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,171.82,341.6,
NF-Trelegy Ellipta Inhalation Powder,3205729,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Jentadueto Oral Tablet 2.5MG-1000MG,3205730,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Trelegy Ellipta Inhalation Powder,3205731,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Dexilant Delayed-Release Capsule 60MG,3205732,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Minipress Capsule 1MG,3205734,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Linzess Oral Capsule 145MCG,3205735,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Fusion Plus Oral Capsule,3205736,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Fusion Plus Oral Capsule,3205737,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Linzess Oral Capsule 145MCG,3205738,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Advair HFA 115/21 Inh Aer 115MCG-21MC,3205739,CDM,250,RC,,,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,116,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3205740,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Depo-Provera IM Susp 150MG/1ML,3205741,CDM,250,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
NF-Linzess Oral Capsule 145MCG,3205742,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-TRILEPTAL ORAL TABLET 150MG,3205743,CDM,250,RC,,,outpatient,,,19.28,14.46,,15.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.76,15.42,
NF-ARIPiprazole Oral Tablet 2MG,3205744,CDM,250,RC,,,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.48,94.4,
NF-Ingrezza Oral Capsule 40MG,3205745,CDM,250,RC,,,outpatient,,,885,663.75,,708,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,486.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,356.12,708,
NF-Tresiba Subcutaneous Solution 200U/1M,3205746,CDM,250,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
NF-Perforomist Inhalation Soln 20MCG/2ML,3205747,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3205748,CDM,250,RC,,,outpatient,,,476,357,,380.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.54,380.8,
NYSTATIN/TRIAMCINOLONE CR. 30 GM,3205749,CDM,637,RC,,,outpatient,,,21.5,16.13,,17.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.65,17.2,
NF-Farxiga Oral Tablet 10MG,3205750,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Imbruvica Oral Tablet 420MG,3205751,CDM,250,RC,,,outpatient,,,1914,1435.5,,1531.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,770.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,957,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,957,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,957,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,957,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1052.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,770.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,770.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1531.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1435.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1531.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,770.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1531.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,770.19,1531.2,
NF-SEROquel XR Oral Tab ER 300MG,3205754,CDM,250,RC,,,outpatient,,,94,70.5,,75.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.83,75.2,
NF-Vraylar Oral Capsule 1.5MG,3205755,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3205756,CDM,250,RC,,,outpatient,,,476,357,,380.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.54,380.8,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205757,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Xtandi Oral Liquid Filled Capsule 40M,3205761,CDM,250,RC,,,outpatient,,,427,320.25,,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,234.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,171.82,341.6,
SIMPLE SYRUP 5ML,3205763,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Anoro Ellipta Inhalation Powder,3205765,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Domperidone Powder,3205766,CDM,250,RC,,,outpatient,,,316,237,,252.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.16,252.8,
NF-Qvar Inh/Neb Aer Liq 0.08MG/1ACT,3205767,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Xeljanz Oral Tablet 10MG,3205768,CDM,250,RC,,,outpatient,,,331,248.25,,264.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.19,264.8,
NF-Jardiance Oral Tablet 25MG,3205769,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Venlafaxine HCl Oral Tab ER 37.5MG,3205772,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-LMR Plus Top Kit 5%;0.5%-0.5%,3205773,CDM,250,RC,,,outpatient,,,16846,12634.5,,13476.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6778.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9265.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6778.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6778.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6778.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,13476.8,
NF-Striverdi Respimat Inh Spray 2.5MCG/1,3205774,CDM,250,RC,,,outpatient,,,235,176.25,,188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.56,188,
NF-Jardiance Oral Tablet 25MG,3205775,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-STRIVERDI RESPIMAT INH SPRAY 2.5MCG/1,3205777,CDM,250,RC,,,outpatient,,,235.14,176.36,,188.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.62,188.11,
NF-Trulance Oral Tablet 3MG,3205778,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-OxyCONTIN Tablet Extended Release 15M,3205782,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Febuxostat Oral Tablet 40MG,3205783,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Loxapine Oral Capsule 50MG,3205784,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Anoro Ellipta Inhalation Powder,3205785,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-lamoTRIgine Oral Tablet 25MG,3205786,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Adderall Oral Tablet 30MG,3205787,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Arimidex Oral Tablet 1MG,3205788,CDM,250,RC,,,outpatient,,,202,151.5,,161.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,81.28,161.6,
NF-Estradiol Transdermal Patch ER  0.025,3205789,CDM,637,RC,,,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
NF-NALFON ORAL TABLET 600MG,3205790,CDM,250,RC,,,outpatient,,,17.99,13.49,,14.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.39,
NF-Anoro Ellipta Inhalation Powder,3205791,CDM,637,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
CALCIUM CARBONATE 750 MG TAB,3205792,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Bevespi Aerosphere Inh 4.8MCG-9MCG/1A,3205793,CDM,250,RC,,,outpatient,,,151,113.25,,120.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.76,120.8,
NF-Farxiga Oral Tablet 10MG,3205794,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205795,CDM,637,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Tresiba Subcutaneous Solution 100U/1M,3205796,CDM,637,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Tresiba Subcutaneous Solution 100U/1M,3205797,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Myrbetriq Oral Tablet 50MG,3205798,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Pradaxa Oral Capsule 75MG,3205799,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Tikosyn Oral Capsule 500MCG,3205800,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Methotrexate Oral Tablet 2.5MG,3205801,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-SULFASALAZINE TAB 500MG,3205803,CDM,250,RC,,,outpatient,,,6.7,5.03,,5.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.7,5.36,
NF-Linzess Oral Capsule 290MCG,3205804,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Concerta Tablet 36MG,3205805,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Toujeo Subcutaneous Solution 300U/1ML,3205810,CDM,250,RC,,,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,306.4,
NF-Urinozinc Prostate Plus Oral Tablet,3205813,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
PRAVASTATIN 10 MG,3205815,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Saphris Sublingual Tablet 10MG,3205817,CDM,250,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
NF-Toujeo Subcutaneous Solution 300U/1ML,3205818,CDM,250,RC,,,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,306.4,
NF-HUMALOG INJ SOLN 100U/1ML,3205819,CDM,250,RC,,,outpatient,,,121.97,91.48,,97.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.08,97.58,
NF-HUMALOG KWIKPEN SUBQ SOLN 100U/1ML,3205821,CDM,250,RC,,,outpatient,,,157,117.75,,125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.18,125.6,
NF-Inderal LA Oral Cap ER 120MG,3205822,CDM,250,RC,,,outpatient,,,112,84,,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.07,89.6,
NF-Namenda XROral Capsule ER 28MG,3205823,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Tresiba Subcutaneous Solution 100U/1M,3205824,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Letrozole Oral Tablet 2.5MG,3205825,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Leflunomide Oral Tablet 20MG,3205826,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Flecainide Acetate Tablet 100MG,3205827,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Letrozole Oral Tablet 2.5MG,3205828,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Effexor-XR Capsule 37.5MG,3205829,CDM,250,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
XOFLUZA 40 MG,3205833,CDM,637,RC,,,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
NF-Vraylar Oral Capsule 3MG,3205835,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Methotrexate Oral Tablet 2.5MG,3205836,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Rebif Injection 44MCG/0.5ML,3205837,CDM,250,RC,,,outpatient,,,5899,4424.25,,4719.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2373.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2949.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2949.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2949.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2949.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3244.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4719.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4424.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4424.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4424.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4424.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2373.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4719.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4424.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4719.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4719.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4719.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2373.76,4719.2,
NF-Breo Ellipta Inhalation Powder,3205840,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Edarbyclor Oral Tablet 40MG-25MG,3205845,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Amitriptyline HCl Oral Tablet 150MG,3205846,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Onglyza Oral Tablet 5MG,3205847,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Entresto Oral Tablet 97MG-103MG,3205848,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Trulance Oral Tablet 3MG,3205849,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Boniva Oral Tablet 150MG,3205852,CDM,637,RC,,,outpatient,,,847,635.25,,677.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,423.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,677.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,635.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,677.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,677.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,340.83,677.6,
NF-Omeprazole Tablet Delayed Release 20M,3205853,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Tradjenta Oral Tablet 5MG,3205854,CDM,250,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-Trelegy Ellipta Inhalation Powder,3205855,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Trintellix Oral Tablet 20MG,3205856,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Breo Ellipta Inhalation Powder,3205857,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Restasis Ophthalmic Emulsion 0.05%,3205858,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205859,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Linzess Oral Capsule 145MCG,3205861,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Linzess Oral Capsule 72MCG,3205862,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Methotrexate Oral Tablet 2.5MG,3205863,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Tresiba Subcutaneous Solution 100U/1M,3205864,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Steglatro Oral Tablet 15MG,3205865,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Chantix Oral Tablet 0.5MG-1MG,3205867,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Chantix Oral Tablet 1MG,3205868,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Myrbetriq Oral Tablet 50MG,3205869,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Pyridostigmine Bromide Oral Tablet 60,3205870,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-fluvoxaMINE Maleate Tablet 100MG,3205872,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Inderal LA Oral Cap ER 60MG,3205878,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
BLOOD TRANSFUSION SERVICE,6100093,CDM,521,RC,36430,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,602.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,690.5,
NF-MITIGARE CAP 0.6MG,3205880,CDM,250,RC,,,outpatient,,,26.57,19.93,,21.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.69,21.26,
NF-Xultophy SubQ Solution 100U-3.6MG/ML,3205881,CDM,250,RC,,,outpatient,,,307,230.25,,245.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.54,245.6,
PESSARY FITTING AND INSERTION,6100117,CDM,521,RC,57160,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,263.25,
NF-Viibryd Oral Tablet 40MG,3205883,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Crestor Tablet 40MG,3205884,CDM,637,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-chlordiazePOXIDE Oral Capsule 25MG,3205886,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Remeron Tablet 15MG,3205887,CDM,637,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Vraylar Oral Capsule 3MG,3205888,CDM,250,RC,,,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,141.6,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205889,CDM,250,RC,,,outpatient,,,441,330.75,,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,177.46,352.8,
NF-Probiotic Oral Capsule 250MG,3205890,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-fluvoxaMINE Maleate Capsule ER 100MG,3205891,CDM,250,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205893,CDM,250,RC,,,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,167.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205896,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3205897,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-pimozide Oral Tablet 1MG,3205898,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-quiNINE Sulfate Oral Capsule 325MG,3205899,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-FLUVOXAMINE MALEATE ORAL TABLET 100MG,3205900,CDM,250,RC,,,outpatient,,,9.77,7.33,,7.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.93,7.82,
XR FACIAL BONES COMP MIN 3 VIEWS,6100168,CDM,320,RC,70150,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,174.35,
NF-Tresiba Subcutaneous Solution 100U/1M,3205903,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
CELEBREX 200MG 340B,3205905,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Tradjenta Oral Tablet 5MG,3205908,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Fenofibrate Oral Tablet 160MG,3205909,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Oxtellar XR Oral Tab ER 600MG,3205910,CDM,250,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
NF-Estradiol Vaginal Cream 0.1MG/1GM,3205911,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-BYDUREON BCise SubQ Susp ER 2MG/0.85M,3205912,CDM,250,RC,,,outpatient,,,941,705.75,,752.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,470.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,470.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,470.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,470.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,517.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,378.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,705.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,378.66,752.8,
ALPRAZOLAM 1 MG,3205913,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-Tricor Oral Tablet 48MG,3205914,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Flecainide Acetate Tablet 100MG,3205915,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Senokot S Oral Tablet 50MG-8.6MG,3205917,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-raNITIdine Oral Capsule 300MG,3205918,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Morphine Sulfate Oral Capsule ER 100M,3205919,CDM,637,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205920,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Soliqua SC Solution 100U-33MCG/1ML,3205921,CDM,250,RC,,,outpatient,,,217,162.75,,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.32,173.6,
NF-Januvia Oral Tablet 100MG,3205922,CDM,637,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205923,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3205924,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
CEFTIN 500 MG E340B,3205926,CDM,637,RC,,,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Glyxambi Oral Tablet 25MG-5MG,3205927,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
FAMOTIDINE 10 MG,3205928,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-Xanax XR Oral Tablet ER 1MG,3205929,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Corlanor Oral Tablet 5MG,3205930,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Buprenorphine HCl SL Tablet 8MG,3205931,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Corlanor Oral Tablet 5MG,3205932,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Buprenorphine HCl SL Tablet 8MG,3205933,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3205934,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Pataday Ophthalmic Solution 0.2%,3205935,CDM,250,RC,,,outpatient,,,331,248.25,,264.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.19,264.8,
NF-Xeljanz Oral Tablet 5MG,3205936,CDM,250,RC,,,outpatient,,,347,260.25,,277.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.63,277.6,
NF-Brimonidine Tartrate Ophth Soln 0.15%,3205937,CDM,250,RC,,,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.91,103.2,
NF-Solifenacin Succinate Oral Tablet 10M,3205940,CDM,250,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
NF-pimozide Oral Tablet 1MG,3205941,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NOVOLIN 70/30 FLEXPEN  (BOX OF 5) E340B,3205942,CDM,637,RC,,,outpatient,,,35.94,26.96,,28.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.46,28.75,
NF-Linzess Oral Capsule 72MCG,3205943,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Asmanex Twisthaler Inh Pwd 0.22MG/1Ac,3205945,CDM,250,RC,,,outpatient,,,998,748.5,,798.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,401.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,499,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,548.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,401.6,798.4,
NF-XANAX XR ORAL TABLET ER 2MG,3205946,CDM,250,RC,,,outpatient,,,62.27,46.7,,49.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.06,49.82,
NF-SAPHRIS SL TAB 10MG,3205947,CDM,250,RC,,,outpatient,,,56.09,42.07,,44.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.57,44.87,
NF-Saphris Sublingual Tablet 10MG,3205948,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Xanax XR Oral Tablet ER 2MG,3205949,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-Chantix Oral Tablet 1MG,3205950,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-Animas Insulin Pump R1000,3205951,CDM,250,RC,,,outpatient,,,24050,18037.5,,19240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9677.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12025,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12025,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12025,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12025,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13227.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18037.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18037.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18037.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18037.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9677.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9677.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18037.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9677.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,19240,
NF-Minipress Capsule 2MG,3205952,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
FAMOTIDINE INJ. 20MG/2ML,3205953,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Brimonidine Tartrate Ophth Soln 0.15%,3205954,CDM,637,RC,,,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.91,103.2,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3205955,CDM,250,RC,,,outpatient,,,505,378.75,,404,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.21,404,
NF-Chlorthalidone Tablet 25MG,3205957,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Januvia Oral Tablet 50MG,3205958,CDM,637,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Xeljanz Oral Tablet 5MG,3205959,CDM,250,RC,,,outpatient,,,347,260.25,,277.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.63,277.6,
NF-Tresiba Subcutaneous Solution 100U/1M,3205960,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205961,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
XR ELBOW 3 VIEWS OR MORE,6100196,CDM,320,RC,73080TC,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Uloric Oral Tablet 40MG,3205964,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
CLOBETASOL PROP. CREAM 0.05% 45GM,3205971,CDM,637,RC,,,outpatient,,,275,206.25,,220,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,110.66,220,
SOD. CHLORIDE 3% 500 ML,3205972,CDM,636,RC,,,both,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,18,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3205973,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Vraylar Oral Capsule 3MG,3205975,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3205976,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-OLOPATADINE HCL OPHTH SOLN 0.2%,3205977,CDM,250,RC,,,outpatient,,,199.68,149.76,,159.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.35,159.74,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205978,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Dexilant Delayed-Release Capsule 60MG,3205979,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Tradjenta Oral Tablet 5MG,3205980,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Farxiga Oral Tablet 10MG,3205981,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
DRYSOL SOLUTION 60 CC,3205983,CDM,637,RC,,,outpatient,,,10.36,7.77,,8.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.17,8.29,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3205984,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205985,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Austedo Oral Tablet 12MG,3205986,CDM,250,RC,,,outpatient,,,429,321.75,,343.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,235.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,172.63,343.2,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3205988,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205989,CDM,637,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Nuedexta Oral Capsule 20MG-10MG,3205990,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-guanFACINE HCl Tablet 2MG,3205991,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Austedo Oral Tablet 12MG,3205992,CDM,250,RC,,,outpatient,,,429,321.75,,343.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,235.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,172.63,343.2,
NF-Invega Sustenna IM Susp ER 117MG,3205993,CDM,637,RC,,,outpatient,,,8303,6227.25,,6642.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3341.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4566.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3341.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3341.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6642.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6642.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3341.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6642.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6642.4,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3205994,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3205995,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Tenuate Dospan Tablet 75MG,3205996,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Leflunomide Oral Tablet 10MG,3205997,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-MYFORTIC ENTERIC-COATED TABLET 180MG,3205998,CDM,637,RC,,,outpatient,,,25.35,19.01,,20.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.2,20.28,
NF-Dexilant Delayed-Release Capsule 30MG,3205999,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Farxiga Oral Tablet 5MG,3206000,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Linzess Oral Capsule 72MCG,3206001,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
DOPAMINE 400MG/10ML VIAL,3206003,CDM,636,RC,,,both,,,9.25,6.94,,7.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.72,9.25,
NF-Pramipexole Dihydrochloride Tab 0.125,3206004,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3206005,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Rayaldee Oral Cap ER 30MCG,3206006,CDM,250,RC,,,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,128,
NF-VIIBRYD ORAL TABLET 20MG,3206010,CDM,250,RC,,,outpatient,,,42.31,31.73,,33.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.03,33.85,
XR HIP BILATERAL AND PELVIS,6100203,CDM,320,RC,73520TC,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Celecoxib Oral Capsule 50MG,3206014,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Celecoxib Oral Capsule 50MG,3206015,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206016,CDM,637,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206017,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Anoro Ellipta Inhalation Powder,3206018,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-NexAVAR Oral Tablet 200MG,3206019,CDM,250,RC,,,outpatient,,,739,554.25,,591.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,297.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,369.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,369.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,369.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,369.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,406.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,297.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,591.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,554.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,591.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,591.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,297.37,591.2,
NF-Anoro Ellipta Inhalation Powder,3206020,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Trelegy Ellipta Inhalation Powder,3206021,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Tikosyn Oral Capsule 250MCG,3206022,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-ESTRADIOL CREAM 10%,3206023,CDM,250,RC,,,outpatient,,,37.19,27.89,,29.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.97,29.75,
NF-Trelegy Ellipta Inhalation Powder,3206024,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206025,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-prednisoLONE Sodium pH Ophth Solution,3206026,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CAPSAICIN CREAM 0.025% 60 G,3206027,CDM,637,RC,,,outpatient,,,13.9,10.43,,11.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.59,11.12,
NF-Linzess Oral Capsule 145MCG,3206028,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-HumuLIN R Concentrate U-500 Inj 500U/,3206029,CDM,250,RC,,,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.79,264,
NF-Atomoxetine Oral Capsule 40MG,3206030,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Anoro Ellipta Inhalation Powder,3206031,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Meloxicam Oral Tablet 15MG,3206032,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Protonix Oral Tab DR 40MG,3206033,CDM,637,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Methotrexate Oral Tablet 2.5MG,3206035,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Tresiba Subcutaneous Solution 100U/1M,3206037,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Minipress Capsule 2MG,3206038,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
DEXMEDETOMIDINE 200MCG/NS 50ML,3206039,CDM,636,RC,,,both,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,210,
NF-EDARBI ORAL TABLET 40MG,3206040,CDM,250,RC,,,outpatient,,,18.47,13.85,,14.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.43,14.78,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3206041,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Anoro Ellipta Inhalation Powder,3206042,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Trelegy Ellipta Inhalation Powder,3206044,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206046,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Vraylar Oral Capsule 3MG,3206047,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Savella Oral Tablet 50MG,3206048,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Anoro Ellipta Inhalation Powder,3206049,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Qvar Inh/Neb Aer Liq 0.08MG/1ACT,3206050,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Xeljanz Oral Tablet 10MG,3206051,CDM,250,RC,,,outpatient,,,347,260.25,,277.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.63,277.6,
NF-Farxiga Oral Tablet 10MG,3206052,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
PROPOFOL 50 ML,3206053,CDM,636,RC,,,both,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.35,63,
NF-Alogliptin Benzoate Oral Tablet 6.25M,3206055,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3206056,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Memantine HCl Oral Capsule ER 28MG,3206057,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Anoro Ellipta Inhalation Powder,3206058,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-traMADol Hydrochloride Oral Tab ER 10,3206059,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
TRIAMCINOLONE 0.1% CR 80 GM,3206060,CDM,636,RC,,,both,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,12,
NF-Tradjenta Oral Tablet 5MG,3206061,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Jardiance Oral Tablet 25MG,3206062,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Glucocard Shine Test Strips Device,3206064,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Anoro Ellipta Inhalation Powder,3206065,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-CeleBREX Oral Capsule 50MG,3206066,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Pataday Ophthalmic Solution 0.2%,3206067,CDM,250,RC,,,outpatient,,,331,248.25,,264.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.19,264.8,
NF-Olopatadine HCl Ophthalmic Solution 0,3206068,CDM,250,RC,,,outpatient,,,263,197.25,,210.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.83,210.4,
NF-Omeprazole Oral Tablet DR 20MG,3206069,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-VIMPAT ORAL TABLET 150MG,3206070,CDM,250,RC,,,outpatient,,,76.75,57.56,,61.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.88,61.4,
NF-Vimpat Oral Tablet 150MG,3206071,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-CAMRESELO TAB 0.02MG-0.1MG;0.01MG,3206074,CDM,250,RC,,,outpatient,,,10.92,8.19,,8.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.39,8.74,
CLOBETASOL OINT. 0.05% 45 GM,3206076,CDM,637,RC,,,outpatient,,,8.76,6.57,,7.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.53,7.01,
NF-Jardiance Oral Tablet 25MG,3206077,CDM,637,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Farxiga Oral Tablet 5MG,3206078,CDM,637,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Methotrexate Oral Tablet 2.5MG,3206079,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206080,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3206081,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Prazosin HCl Oral Capsule 1MG,3206082,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
EST LEVEL 2 OV,6100314,CDM,521,RC,99212,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,134.33,
NF-Docusate Sodium/Sennoside Tab 50MG-8.,3206086,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Rivastigmine Tartrate Oral Capsule 3M,3206087,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Remeron Tablet 15MG,3206088,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Docusate Sodium/Sennoside Tab 50MG-8.,3206089,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Linzess Oral Capsule 145MCG,3206090,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Pazeo Ophthalmic Solution 0.7%,3206095,CDM,250,RC,,,outpatient,,,364,273,,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,182,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.47,291.2,
NF-Restasis Ophthalmic Emulsion 0.05%,3206096,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Trelegy Ellipta Inhalation Powder,3206097,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Nuedexta Oral Capsule 20MG-10MG,3206098,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Trelegy Ellipta Inhalation Powder,3206099,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Restasis Ophthalmic Emulsion 0.05%,3206100,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Pioglitazone HCl/Glimepiride Tab30MG-,3206101,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Prazosin Hydrochloride Oral Capsule 2,3206103,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Prazosin Hydrochloride Oral Capsule 2,3206104,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Creon Oral Delayed Release Capsule,3206105,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Corlanor Oral Tablet 5MG,3206106,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
HYDROCHLOROTHIAZIDE 12.5 MG,3206108,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-GLIPIZIDE/METFORMIN HCL TAB 5MG-500MG,3206109,CDM,250,RC,,,outpatient,,,3.66,2.75,,2.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.47,2.93,
NF-Linzess Oral Capsule 145MCG,3206112,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-clomiPRAMINE HCl Capsule 50MG,3206113,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Creon Oral Delayed Release Capsule,3206115,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Glyxambi Oral Tablet 25MG-5MG,3206116,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Ozempic 0.25MG or 0.5MG Doses 2MG/1.5,3206117,CDM,250,RC,,,outpatient,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,965.76,1920,
NF-Linzess Oral Capsule 145MCG,3206118,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Trelegy Ellipta Inhalation Powder,3206119,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Fusion Plus Oral Capsule,3206120,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Vascepa Oral Liquid Filled Cap 1GM,3206121,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Creon Oral Delayed Release Capsule,3206122,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-VITAMIN B6 ORAL TABLET 100MG,3206124,CDM,250,RC,,,outpatient,,,0.21,0.16,,0.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.17,
NF-Rybelsus Oral Tablet 3MG,3206125,CDM,250,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
NF-Creon Oral Delayed Release Capsule,3206129,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Creon Oral Delayed Release Capsule,3206130,CDM,637,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206131,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Trelegy Ellipta Inhalation Powder,3206132,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Nexletol Oral Tab 180MG,3206133,CDM,637,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Repatha Subcutaneous Solution 140MG/1,3206134,CDM,637,RC,,,outpatient,,,999,749.25,,799.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,549.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402,799.2,
NF-Ozempic 0.25MG or 0.5MG Doses 2MG/1.5,3206135,CDM,250,RC,,,outpatient,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,965.76,1920,
NF-Arimidex Tablet 1MG,3206136,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Nateglinide Oral Tablet 60MG,3206137,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Entresto Oral Tablet 97MG-103MG,3206138,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Vraylar Oral Capsule 1.5MG,3206139,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Creon Oral Delayed Release Capsule,3206140,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206141,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Savella Oral Tablet 50MG,3206142,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Vraylar Oral Capsule 3MG,3206143,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Ubrelvy Oral Tablet 100MG,3206144,CDM,250,RC,,,outpatient,,,377,282.75,,301.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,151.7,301.6,
AC VISIT LEVEL I,6100326,CDM,987,RC,99231,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,77.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,68.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,25.81,77.98,
NF-SALSALATE ORAL TABLET 500MG,3206147,CDM,250,RC,,,outpatient,,,6.66,5,,5.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.68,5.33,
NF-Salsalate Oral Tablet 500MG,3206148,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Prazosin HCl Oral Capsule 1MG,3206149,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Restasis Ophthalmic Emulsion 0.05%,3206150,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-DOXEPIN HCL CAP 100MG,3206153,CDM,250,RC,,,outpatient,,,7.3,5.48,,5.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.94,5.84,
NF-Jardiance Oral Tablet 25MG,3206154,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Doxepin HCl Oral Capsule 100MG,3206155,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Vraylar Oral Capsule 3MG,3206156,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-CRANBERRY ORAL CAPSULE 405MG,3206158,CDM,250,RC,,,outpatient,,,0.22,0.17,,0.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.09,0.18,
NF-Fluorometholone Ophth Suspension 0.1%,3206160,CDM,250,RC,,,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.35,50.4,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3206161,CDM,637,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3206162,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Breo Ellipta Inhalation Powder,3206163,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Linzess Oral Capsule 72MCG,3206164,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
DILTIAZEM ER 180 MG  E340B,3206165,CDM,636,RC,,,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Farxiga Oral Tablet 10MG,3206166,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
CONSULT OV LEVEL I,6100334,CDM,521,RC,99241,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Acitretin Oral Capsule 10MG,3206170,CDM,250,RC,,,outpatient,,,115,86.25,,92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.28,92,
NF-Relistor Oral Tablet 150MG,3206171,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Viibryd Oral Tablet 10MG,3206172,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Relistor Oral Tablet 150MG,3206173,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Asmanex Twisthaler Inh Pwd 0.22MG/1Ac,3206175,CDM,250,RC,,,outpatient,,,1430,1072.5,,1144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,715,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,715,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,786.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575.43,1144,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206177,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3206180,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Aromasin Oral Tablet 25MG,3206182,CDM,250,RC,,,outpatient,,,163,122.25,,130.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.59,130.4,
NF-Femara Tablet 2.5MG,3206183,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-Linzess Oral Capsule 290MCG,3206184,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Nexletol Oral Tab 180MG,3206186,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206189,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Repatha Subcutaneous Solution 140MG/1,3206190,CDM,250,RC,,,outpatient,,,999,749.25,,799.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,549.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402,799.2,
NF-Frova Oral Tablet 2.5MG,3206192,CDM,250,RC,,,outpatient,,,433,324.75,,346.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,174.24,346.4,
NF-Letrozole Oral Tablet 2.5MG,3206193,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Maxalt Tablet 10MG,3206194,CDM,250,RC,,,outpatient,,,162,121.5,,129.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.19,129.6,
NF-Invokana Oral Tablet 300MG,3206195,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Linzess Oral Capsule 145MCG,3206197,CDM,637,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Linzess Oral Capsule 290MCG,3206198,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3206199,CDM,250,RC,,,outpatient,,,505,378.75,,404,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.21,404,
MYDRIACIL 1% OPHTH 15ML SOLN,3206200,CDM,637,RC,,,outpatient,,,2.27,1.7,,1.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.91,1.82,
NEO-SYNEPHRINE 2.5% OPHTH 5ML SOLN,3206201,CDM,637,RC,,,outpatient,,,1.68,1.26,,1.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.68,1.34,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206202,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
BUPIVICAINE 0.75% 10ML INJ,3206203,CDM,250,RC,,,outpatient,,,8.25,6.19,,6.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.32,6.6,
NF-Cellcept Tablet 500MG,3206208,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Envarsus XR Tab Extended Release 1MG,3206209,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-Envarsus XR Tab Extended Release 4MG,3206210,CDM,250,RC,,,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.63,76.8,
NF-Dextroamphetamine Sulfate Cap ER 10MG,3206211,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Farxiga Oral Tablet 10MG,3206212,CDM,637,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Buprenorphine HCl SL Tablet 8MG,3206214,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Tricor Oral Tablet 48MG,3206216,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-CALCIUM 600 PLUS VIT D3 TAB 400IU-600,3206217,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-Linzess Oral Capsule 145MCG,3206221,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Neurontin Capsule 400MG,3206222,CDM,637,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Naltrexone Hydrochloride Tablet 50MG,3206223,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Entresto Oral Tablet 49MG-51MG,3206224,CDM,637,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Acidophilus ES 35-25 Million ORG,3206225,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Colace Liquid Capsule 100MG,3206226,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Emgality Subcutaneous Solution 100MG/,3206227,CDM,250,RC,,,outpatient,,,2233,1674.75,,1786.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,898.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1228.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1786.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,898.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,898.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1786.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1674.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1786.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1786.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,898.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1786.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,898.56,1786.4,
NF-Linzess Oral Capsule 145MCG,3206228,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Ozempic 1MG Doses SubQ Soln 2MG/1.5ML,3206229,CDM,250,RC,,,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
NF-Xigduo XR Oral Tablet ER 10MG-1000MG,3206230,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206231,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Dexilant Delayed-Release Capsule 60MG,3206232,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Fenofibrate Micronized Cap 134MG,3206233,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-DAPTOmycin IV Pwd for Soln 500MG,3206235,CDM,250,RC,,,outpatient,,,1977,1482.75,,1581.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1087.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,795.54,1581.6,
NF-DAPTOmycin IV Pwd for Soln 500MG,3206236,CDM,637,RC,,,outpatient,,,1977,1482.75,,1581.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1087.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,795.54,1581.6,
NF-DAPTOmycin IV Pwd for Soln 500MG,3206240,CDM,250,RC,,,outpatient,,,1977,1482.75,,1581.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1087.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,795.54,1581.6,
NF-AVAPRO ORAL TABLET 300MG,3206241,CDM,250,RC,,,outpatient,,,16.41,12.31,,13.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.6,13.13,
NF-Alogliptin Benzoate Oral Tablet 12.5M,3206242,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Linzess Oral Capsule 72MCG,3206243,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-buPROPion Hydrochloride Tablet 100MG,3206246,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Linzess Oral Capsule 145MCG,3206247,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NADOLOL 80 MG,3206248,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Tresiba Subcutaneous Solution 100U/1M,3206250,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Linzess Oral Capsule 145MCG,3206251,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Atomoxetine Oral Capsule 80MG,3206253,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Atomoxetine Oral Capsule 40MG,3206254,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Vraylar Oral Capsule 3MG,3206255,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Vitamin A Palmitate Solution,3206256,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trelegy Ellipta Inhalation Powder,3206259,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Femara Tablet 2.5MG,3206261,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-Entresto Oral Tablet 97MG-103MG,3206262,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-dofetilide Oral Capsule 250MCG,3206263,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Rhopressa Ophthalmic Solution 0.02%,3206264,CDM,250,RC,,,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,194.36,386.4,
NF-Trelegy Ellipta Inhalation Powder,3206265,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Trelegy Ellipta Inhalation Powder,3206266,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Trelegy Ellipta Inhalation Powder,3206267,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-TRELEGY ELLIPTA INHALATION POWDER,3206269,CDM,250,RC,,,outpatient,,,42.42,31.82,,33.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.07,33.94,
NF-TRELEGY ELLIPTA INHALATION POWDER,3206270,CDM,250,RC,,,outpatient,,,42.42,31.82,,33.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.07,33.94,
NF-Dexilant Delayed-Release Capsule 60MG,3206271,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Linzess Oral Capsule 145MCG,3206272,CDM,637,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Myrbetriq Oral Tablet 50MG,3206273,CDM,637,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-Linzess Oral Capsule 145MCG,3206274,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Myrbetriq Oral Tablet 50MG,3206275,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-Methotrexate Oral Tablet 2.5MG,3206281,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Restoril Capsule 30MG,3206282,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Rybelsus Oral Tablet 7MG,3206283,CDM,250,RC,,,outpatient,,,121,90.75,,96.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.69,96.8,
NF-Femara Tablet 2.5MG,3206284,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-Linzess Oral Capsule 290MCG,3206285,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Aeroeclipse Nebulizer,3206286,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
"NF-Procrit Injection 10,000U/ML",3206287,CDM,250,RC,,,outpatient,,,1186,889.5,,948.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,477.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,593,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,593,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,593,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,593,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,652.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,477.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,477.25,948.8,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206290,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Albuterol Sulfate HFA Inh 0.09MG/1ACT,3206291,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Albuterol Sulfate HFA InhSusp0.09MG/1,3206292,CDM,637,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Vraylar Oral Capsule 1.5MG,3206293,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Dexilant Delayed-Release Capsule 60MG,3206295,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Austedo Oral Tablet 9MG,3206296,CDM,250,RC,,,outpatient,,,322,241.5,,257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,161,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,129.57,257.6,
NF-Trileptal Oral Tablet 150MG,3206297,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Aimovig 70MG SubQ Solution,3206298,CDM,250,RC,,,outpatient,,,2678,2008.5,,2142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1472.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1077.63,2142.4,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206299,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Trelegy Ellipta Inhalation Powder,3206300,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Linzess Oral Capsule 290MCG,3206301,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
FINASTERIDE 1 MG TABLET,3206302,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Hydrocortisone Tablet 20MG,3206303,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Alphagan P Opthamalic Solution  0.1%,3206304,CDM,250,RC,,,outpatient,,,149,111.75,,119.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.96,119.2,
NURSING HOME ADMIT,6100362,CDM,522,RC,T1015,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Micardis Oral Tablet 20MG,3206308,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206309,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Trelegy Ellipta Inhalation Powder,3206310,CDM,250,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Jardiance Oral Tablet 25MG,3206312,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Linzess Oral Capsule 290MCG,3206313,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Flector Topical Patch ER 1.3%,3206315,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Vraylar Oral Capsule 3MG,3206316,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Prazosin HCl Capsule 5MG,3206317,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Jardiance Oral Tablet 10MG,3206321,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Vraylar Oral Capsule 1.5MG,3206322,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206324,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206325,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206326,CDM,250,RC,,,outpatient,,,467,350.25,,373.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.92,373.6,
NF-Anoro Ellipta Inhalation Powder,3206327,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Linzess Oral Capsule 145MCG,3206329,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-clomiPRAMINE HCl Capsule 50MG,3206330,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Breztri Aerosphere Inh Aer Liq,3206331,CDM,250,RC,,,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
NEW PT LEVEL 1 OV,6100385,CDM,521,RC,99201,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-FIBERSOURCE HN ORAL SUSPENSION,3206334,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
LEVSIN O.125MG SL,3206335,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Dexilant Delayed-Release Capsule 60MG,3206336,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Vascepa Oral Liquid Filled Cap 1GM,3206337,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3206338,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206339,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Dexilant Delayed-Release Capsule 60MG,3206340,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206341,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Alvesco Oral Aerosol Liquid 80MCG/1Ac,3206342,CDM,250,RC,,,outpatient,,,183,137.25,,146.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.64,146.4,
NF-Xigduo XR Oral Tablet ER 10MG-1000MG,3206343,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
CICLOPIROX OLAMINE CREAM 0.77%  90 GR,3206344,CDM,637,RC,,,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,100.8,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3206346,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Anoro Ellipta Inhalation Powder,3206347,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Linzess Oral Capsule 145MCG,3206348,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
CHLORDIAZEPOXIDE HCL 10 MG,3206349,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REGENERON 1200MG/ NSS 250 ML,3206350,CDM,250,RC,Q0244,HCPCS,outpatient,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Minipress Capsule 5MG,3206351,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Aimovig 70MG SubQ Solution,3206352,CDM,250,RC,,,outpatient,,,2678,2008.5,,2142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1472.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1077.63,2142.4,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3206354,CDM,250,RC,,,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,885,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,1416,
NF-Linzess Oral Capsule 145MCG,3206355,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Edarbyclor Oral Tablet 40MG-25MG,3206356,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Linzess Oral Capsule 145MCG,3206357,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-CeleBREX Capsule 100MG,3206358,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-PHENobarbital Oral Tablet 64.8MG,3206359,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Esomeprazole Magnesium Capsule DR 40M,3206360,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Alvesco Oral Aerosol Liquid 80MCG/1Ac,3206362,CDM,250,RC,,,outpatient,,,183,137.25,,146.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.64,146.4,
NF-Xigduo XR Oral Tablet ER 10MG-1000MG,3206363,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Myrbetriq Oral Tablet 50MG,3206364,CDM,250,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-Anoro Ellipta Inhalation Powder,3206365,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Imitrex Oral Tablet 25MG,3206367,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Tresiba Subcutaneous Solution 100U/1M,3206368,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Albuterol Sulfate Inh/Neb Soln 0.021%,3206370,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Artificial Tear Ophthalmic Ointment,3206371,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Femara Tablet 2.5MG,3206373,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-Buprenorphine/Naloxone SL Tab 8MG-2MG,3206374,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Procrit Injection Solution 20000U/1ML,3206376,CDM,637,RC,,,outpatient,,,2373,1779.75,,1898.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,954.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1186.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1186.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1186.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1305.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,954.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,954.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1779.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,954.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,954.9,1898.4,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206377,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206378,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3206380,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
IVERMECTIN 3 MG TABLET,3206382,CDM,636,RC,,,both,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,5.5,
NF-VP-Vite Rx Oral Tablet,3206383,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Jardiance Oral Tablet 10MG,3206385,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Minipress Capsule 5MG,3206386,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Myrbetriq Oral Tablet ER 25MG,3206387,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Amitiza Oral Liquid Filled Capsule 8M,3206388,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Pulmicort Flexhaler Inh/Neb 180MCG/1A,3206389,CDM,250,RC,,,outpatient,,,1140,855,,912,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,570,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,570,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,570,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,458.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,458.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,458.74,912,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3206391,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Budesonide Oral Cap DR 3MG,3206392,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Repatha Subcutaneous Solution 140MG/1,3206394,CDM,250,RC,,,outpatient,,,2480,1860,,1984,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1364,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,997.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,997.95,1984,
NF-clomiPRAMINE HCl Capsule 50MG,3206398,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Trelegy Ellipta Inhalation Powder,3206399,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Linzess Oral Capsule 145MCG,3206400,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Rayaldee Oral Cap ER 30MCG,3206401,CDM,250,RC,,,outpatient,,,169,126.75,,135.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.01,135.2,
NF-Linzess Oral Capsule 145MCG,3206402,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Tresiba Subcutaneous Solution 200U/1M,3206403,CDM,250,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
NF-HumuLIN R Concentrated U-500 KwikPen,3206404,CDM,250,RC,,,outpatient,,,424,318,,339.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,170.62,339.2,
NF-Trelegy Ellipta Inhalation Powder,3206405,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Linzess Oral Capsule 145MCG,3206406,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Jardiance Oral Tablet 25MG,3206407,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Chlorthalidone Tablet 25MG,3206408,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Lisinopril Tablet 5mg,3206410,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Omeprazole Delayed-Release Capsule 40,3206412,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-ProAir RespiClick Inh Powder 0.09MG/1,3206413,CDM,250,RC,,,outpatient,,,277,207.75,,221.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,111.46,221.6,
NF-Methenamine Hippurate 1GM Tablet,3206415,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3206417,CDM,250,RC,,,outpatient,,,530,397.5,,424,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,213.27,424,
NF-Nortriptyline Oral Capsule 50MG,3206418,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-fluPHENAZine HCl Tablet 2.5MG,3206420,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Jardiance Oral Tablet 25MG,3206421,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Linzess Oral Capsule 290MCG,3206422,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Trelegy Ellipta Inhalation Powder,3206423,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Corlanor Oral Tablet 5MG,3206424,CDM,250,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
NF-Cyclobenzaprine HCl Oral Tablet 5MG,3206428,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-oxyCODONE HCl Oral Tab 15MG,3206430,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Linzess Oral Capsule 290MCG,3206431,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Vraylar Oral Capsule 3MG,3206432,CDM,637,RC,,,outpatient,,,187,140.25,,149.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.25,149.6,
NF-Prevacid Delayed-Release Capsule 15MG,3206437,CDM,637,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Atorvastatin Calcium Oral Tab 80MG,3206439,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-QUEtiapine Fumarate Oral Tablet 300MG,3206440,CDM,637,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
SODIUM CHLORIDE TAB 1 GRAM,3206441,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
CHLORTHALIDONE 25 MG,3206442,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-acetaZOLAMIDE Capsule ER 500MG,3206443,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Atomoxetine Oral Capsule 40MG,3206444,CDM,250,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Artificial Tears Ophth Solution,3206445,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Synalar Topical Solution 0.01%,3206446,CDM,637,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Doxycycline Oral Tablet 50MG,3206447,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Farxiga Oral Tablet 5MG,3206451,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206452,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Skelaxin Oral Tablet 800MG,3206453,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-traMADol HCl Oral Cap ER 200MG,3206454,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Genvoya Oral Tablet,3206455,CDM,637,RC,,,outpatient,,,502,376.5,,401.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,251,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,251,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,251,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,276.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,202,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,202,401.6,
NF-Genvoya Oral Tablet,3206456,CDM,250,RC,,,outpatient,,,435,326.25,,348,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.04,348,
NF-Genvoya Oral Tablet,3206457,CDM,637,RC,,,outpatient,,,435,326.25,,348,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,175.04,348,
NF-Methylphenidate HCl Oral Tab ER 27MG,3206458,CDM,250,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
NF-Remeron Oral Tablet 15MG,3206461,CDM,637,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Doxazosin Oral Tablet 8MG,3206463,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
"NF-Synjardy XR Oral Tablet, ER 10MG-1000",3206467,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Zenpep Oral Delayed Release Capsule,3206468,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Amitriptyline HCl Tablet 100MG,3206470,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Omeprazole-Sod Bicarbonate 40MG-1100M,3206471,CDM,637,RC,,,outpatient,,,420,315,,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,231,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,169.01,336,
NF-Ondansetron Oral Disintegrating Tab 4,3206472,CDM,637,RC,,,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,65.6,
NF-Trigels-F Forte Liquid Filled Capsule,3206473,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Pepcid Complete Chewable Tab,3206474,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Ambien CR Extended-Release Tablet 12.,3206475,CDM,250,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
NF-Rosuvastatin Calcium Oral Tablet 40MG,3206476,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Lovaza Oral Liquid Filled Capsule 1GM,3206478,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Breztri Aerosphere Inh Aer Liq,3206479,CDM,250,RC,,,outpatient,,,244,183,,195.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.19,195.2,
NF-Trokendi XR Oral Capsule ER 25MG,3206480,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Tikosyn Oral Capsule 250MCG,3206481,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Triamcinolone Acetonide Oint 0.5%,3206482,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Amiodarone HCl Tablet 100MG,3206483,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Spironolactone Tablet 100MG,3206485,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
LIDOCAINE WITH EPI 1% 10MG/ML 20  ML,3206486,CDM,636,RC,,,both,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,20,
NF-Hyoscyamine Sulfate Oral Tablet 0.125,3206487,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Letrozole Oral Tablet 2.5MG,3206488,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Lubricating Eye Drops OphthSoln0.4%-0,3206489,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206490,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Maxzide Tablet 25MG-37.5MG,3206491,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Omeprazole Oral Capsule DR 40MG,3206492,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-ZyPREXA Oral Tablet 20MG,3206493,CDM,637,RC,,,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,261.6,
NF-chlordiazePOXIDE/Amitrip Tab 5-12.5MG,3206494,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-levocetirizine DiHCl Oral Tablet 5MG,3206496,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206497,CDM,250,RC,,,outpatient,,,486,364.5,,388.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,195.57,388.8,
NF-Latuda Oral Tablet 80MG,3206499,CDM,250,RC,,,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.08,159.2,
NF-Celecoxib Oral Capsule 200MG,3206500,CDM,637,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206504,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-OXcarbazepine Oral Tablet 150MG,3206505,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Moexipril Tablet 15MG,3206509,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Methotrexate Oral Tablet 2.5MG,3206510,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Celecoxib Oral Capsule 200MG,3206511,CDM,637,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Humira SubQ Kit 40MG/0.8ML,3206513,CDM,250,RC,,,outpatient,,,13249,9936.75,,10599.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5331.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6624.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6624.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6624.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6624.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7286.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10599.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9936.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9936.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9936.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9936.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5331.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5331.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10599.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9936.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10599.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10599.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5331.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,10599.2,
NF-Isosorbide Mononitrate Tablet 10MG,3206514,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206515,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-CeleBREX Oral Capsule 200MG,3206517,CDM,637,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Omeprazole Tablet Delayed Release 20M,3206518,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Nuzyra Oral Tablet 150MG,3206520,CDM,250,RC,,,outpatient,,,962,721.5,,769.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,387.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,481,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,481,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,481,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,481,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,529.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,387.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,769.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,721.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,769.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,387.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,769.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,387.11,769.6,
NF-ATOMOXETINE ORAL CAPSULE 40MG,3206521,CDM,250,RC,,,outpatient,,,57.22,42.92,,45.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.47,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.03,45.78,
NF-ATOMOXETINE ORAL CAPSULE 40MG,3206523,CDM,250,RC,,,outpatient,,,28.07,21.05,,22.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.3,22.46,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3206524,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Restasis Ophthalmic Emulsion 0.05%,3206525,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Vascepa Oral Liquid Filled Cap 1GM,3206526,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Doxepin Oral Capsule 150MG,3206527,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Amitriptyline HCl Tablet 50MG,3206528,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Buprenorphine SL Tab 2MG,3206529,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Flecainide Acetate Tablet 100MG,3206530,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Femara Tablet 2.5MG,3206531,CDM,250,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
NF-Albuterol Sulfate Inh Susp 0.09MG/1Ac,3206532,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Breo Ellipta Inhalation Powder,3206533,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Nystatin Powder,3206534,CDM,637,RC,,,outpatient,,,973,729.75,,778.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,391.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,486.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,486.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,486.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,486.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,535.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,778.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,391.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,778.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,729.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,778.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,778.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,391.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,778.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,391.54,778.4,
NF-Trulance Oral Tablet 3MG,3206536,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Lisinopril Oral Tablet 5MG,3206540,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Cyclobenzaprine Hydrochloride Tab 5MG,3206541,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
COVID 19 VACCINE (PFIZER) PURPLE CAP,3206542,CDM,636,RC,91300,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Breo Ellipta Inhalation Powder,3206543,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Jardiance Oral Tablet 10MG,3206544,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Jardiance Oral Tablet 10MG,3206545,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-acetaZOLAMIDE Capsule ER 500MG,3206546,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Ajovy Subcutaneous Solution 225MG/1.5,3206548,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Flector Topical Patch ER 1.3%,3206549,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Trulance Oral Tablet 3MG,3206551,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206552,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Tresiba Subcutaneous Solution 100U/1M,3206554,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3206555,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Jardiance Oral Tablet 25MG,3206556,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Estradiol/Norethindrone Acetate Table,3206557,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-levocetirizine DiHCl Oral Tablet 5MG,3206558,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Nortriptyline Hydrochloride Cap 50MG,3206559,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Jardiance Oral Tablet 10MG,3206561,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Nortriptyline HCl Capsule 25MG,3206562,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NH SUBSEQUENT LEVEL 1,6100496,CDM,525,RC,99307,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Lo Loestrin Fe Oral Tab,3206565,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-Linzess Oral Capsule 290MCG,3206568,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3206569,CDM,250,RC,,,outpatient,,,530,397.5,,424,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,213.27,424,
NF-Advair Diskus 100/50 Disk,3206570,CDM,637,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Albuterol Sulfate Inh Soln 1.25MG/3ML,3206571,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-dilTIAZem Extended-Release Capsule 18,3206572,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
SANTYL OINTMENT 90 GM,3206574,CDM,637,RC,,,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
NF-PARoxetine Hydrochloride Tab ER 25MG,3206576,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Depakote Delayed-Release Tablet 125MG,3206577,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-clomiPRAMINE HCl Capsule 50MG,3206578,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Propranolol Hydrochloride Cap ER 160M,3206579,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-FLUoxetine HCl Oral Tablet 60MG,3206580,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-rizatriptan benzoate Oral Tablet 10MG,3206581,CDM,637,RC,,,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.09,97.6,
NF-Trokendi XR Oral Capsule ER 200MG,3206582,CDM,250,RC,,,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.81,136.8,
NF-Ambien CR Extended-Release Tablet 12.,3206583,CDM,250,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
NF-Bystolic Oral Tablet 2.5MG,3206585,CDM,637,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Pantoprazole Sodium Tab EC 40MG,3206586,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-NexIUM Capsule 40MG,3206587,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-KlonoPIN Tablet 2MG,3206588,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Rexulti Oral Tablet 3MG,3206589,CDM,250,RC,,,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.04,147.2,
NF-Anoro Ellipta Inhalation Powder,3206590,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-diazePAM Intensol Concentrate 5MG/ML,3206591,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Linzess Oral Capsule 290MCG,3206592,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-LORazepam Oral Solution 2MG/1ML,3206593,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Morphine Sulfate Oral Solution 20MG/1,3206594,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Esomeprazole Magnesium Oral Cap DR 40,3206596,CDM,637,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
AUGMENTIN SUSP 250MG/5ML    100 ML,3206599,CDM,636,RC,,,both,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,95,
XR HIP BILATERAL AND PELVIS,6100540,CDM,320,RC,73522TC,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Spironolactone Tablet 100MG,3206601,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Mycophenolic Acid Oral Tab DR 180MG,3206602,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Plaquenil Oral Tablet 200MG,3206603,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Mycophenolic Acid Oral Tab EC 180MG,3206604,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
DESVENLAFAXINE ER 100 MG,3206605,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Lotrel Oral Capsule 10MG-40MG,3206606,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Doxazosin Mesylate Tablet 8MG,3206607,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-hydroCHLOROthiazide Oral Capsule 12.5,3206611,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-rizatriptan benzoate Oral Tablet 10MG,3206612,CDM,250,RC,,,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.09,97.6,
NF-RETACRIT INJ SOLN 40000U/1ML,3206613,CDM,250,RC,,,outpatient,,,1958.93,1469.2,,1567.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,788.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,979.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,979.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,979.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,979.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1077.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1567.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,788.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,788.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1567.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1469.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1567.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1567.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,788.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1567.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,788.27,1567.14,
NF-Anoro Ellipta Inhalation Powder,3206616,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Anoro Ellipta Inhalation Powder,3206618,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Methenamine Hippurate 1GM Tablet,3206619,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Methenamine Hippurate 1GM Tablet,3206621,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Glyxambi Oral Tablet 25MG-5MG,3206623,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Jardiance Oral Tablet 10MG,3206624,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Vraylar Oral Capsule 3MG,3206625,CDM,250,RC,,,outpatient,,,187,140.25,,149.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.25,149.6,
NF-Creon Oral Delayed Release Capsule,3206627,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Vascepa Oral Liquid Filled Cap 1GM,3206628,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-clomiPRAMINE HCl Capsule 25MG,3206630,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Breztri Aerosphere Inh Aer Liq,3206631,CDM,250,RC,,,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
NF-glyBURIDE/metFORMIN HCl Oral Tablet,3206632,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Systane Ophth Solution,3206634,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Docusate Sodium w/Sennosides 50MG-8.6,3206635,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Nystatin Powder,3206636,CDM,637,RC,,,outpatient,,,9767,7325.25,,7813.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3930.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4883.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4883.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4883.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4883.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5371.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7813.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7325.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7325.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7325.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7325.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3930.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3930.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7813.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7325.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7813.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7813.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3930.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7813.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7813.6,
NF-Stiolto Respimat Inst Pack 28ACT,3206638,CDM,250,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
NF-Jardiance Oral Tablet 10MG,3206639,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Flecainide Acetate Tablet 100MG,3206640,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206641,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Voriconazole IV Pwd for Soln 200MG,3206642,CDM,637,RC,,,outpatient,,,325,243.75,,260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.78,260,
NF-VORICONAZOLE IV PWD FOR SOLN 200MG,3206643,CDM,250,RC,,,outpatient,,,564.58,423.44,,451.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,282.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,310.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,227.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,451.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,451.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,451.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,227.19,451.66,
NF-Hyoscyamine Sulfate SL Tablet 0.125MG,3206644,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Betamethasone Dipropionat Ointment 0.,3206651,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Capecitabine Oral Tablet 500MG,3206654,CDM,250,RC,,,outpatient,,,144,108,,115.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.95,115.2,
NF-Sildenafil Tablet 100MG,3206657,CDM,250,RC,,,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3206658,CDM,250,RC,,,outpatient,,,486,364.5,,388.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,243,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,195.57,388.8,
NF-Linzess Oral Capsule 290MCG,3206659,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Benztropine Mesylate Oral Tablet 0.5M,3206660,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-PHENobarbital Oral Tablet 64.8MG,3206662,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-RisperDAL Tablet 3MG,3206663,CDM,250,RC,,,outpatient,,,99,74.25,,79.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.84,79.2,
NF-Lotrimin Ultra Topical Cream 1%,3206665,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-CLOTRIMAZOLE SOLN 1%,3206666,CDM,250,RC,,,outpatient,,,9.22,6.92,,7.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.71,7.38,
NF-Salsalate Oral Tablet 750MG,3206668,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
TISSEEL 2 ML KIT (FIBRIN SEALANT),3206671,CDM,636,RC,,,both,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,349.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,349.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,349.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,349.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.28,699,
NF-Benazepril Oral Tablet 40MG,3206672,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Breztri Aerosphere Inh Aer Liq,3206673,CDM,250,RC,,,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
TRANSFUSION BLOOD OR BLOOD COMPONENTS,6200303,CDM,360,RC,36430,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,602.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,690.5,
NF-Amitriptyline HCl Oral Tablet 75MG,3206678,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
"NF-buPROPion HCl Oral Tab ER, 12HR",3206679,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Trulicity SubQ Soln 3MG/0.5ML,3206680,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
OLUMIANT 2 MG TABLET,3206681,CDM,637,RC,,,outpatient,,,155,116.25,,124,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,62.37,124,
NF-Escitalopram Oral Tablet 5MG,3206682,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Doxycycline Oral Tablet 100MG,3206683,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
HYDROXYZINE HCL 50 MG TAB,3206684,CDM,636,RC,,,both,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,2,
NF-Propranolol Hydrochloride Cap ER 60MG,3206685,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
VANCOMYCIN 125 MG CAPSULE,3206687,CDM,637,RC,,,outpatient,,,33.15,24.86,,26.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.34,26.52,
NF-Suboxone Sublingual Film 8MG-2MG,3206689,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-valsartan Oral Tablet 320MG,3206690,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-Vraylar Oral Capsule 3MG,3206691,CDM,637,RC,,,outpatient,,,187,140.25,,149.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.25,149.6,
NF-Levocetirizine DiHCl Oral Tablet 5MG,3206694,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Escitalopram Oral Tablet 5MG,3206696,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Myrbetriq Oral Tablet 50MG,3206699,CDM,250,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-ACEBUTOLOL HCL CAPSULE 400MG,3206701,CDM,250,RC,,,outpatient,,,4.96,3.72,,3.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2,3.97,
NF-TROSPIUM CHLORIDE ORAL TABLET 20MG,3206702,CDM,250,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
NF-Acebutolol HCl Capsule 400MG,3206704,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Trospium Chloride Oral Tablet 20MG,3206705,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Nuzyra Oral Tablet 150MG,3206708,CDM,250,RC,,,outpatient,,,1007,755.25,,805.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,553.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,405.22,805.6,
NF-prednisoLONE Sodium pH Ophth Solution,3206710,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-PoDiaPN Oral Capsule,3206711,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Exelon Capsule 3MG,3206712,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-NALTREXONE HCL TAB 50MG,3206714,CDM,250,RC,,,outpatient,,,15.82,11.87,,12.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.37,12.66,
NF-Leflunomide Oral Tablet 20MG,3206716,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
LIDOCAINE 4% TOPICAL SOLUTION 5ML,3206718,CDM,636,RC,,,both,,,15.62,11.72,,12.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.29,15.62,
NF-Nuzyra Oral Tablet 150MG,3206722,CDM,250,RC,,,outpatient,,,1007,755.25,,805.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,755.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,405.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,805.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,405.22,805.6,
COVID VACCINE (DOSE 2) PFIZER PURPLE CAP,3206723,CDM,636,RC,91300,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
COVID VACCINE (DOSE 3) PFIZER PURPLE CAP,3206724,CDM,636,RC,91300,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-HydrOXYzine HCl Tablet 50MG,3206729,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Trulance Oral Tablet 3MG,3206730,CDM,250,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-Jentadueto XR Oral Tablet ER 5MG-1000,3206731,CDM,637,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Restasis Ophthalmic Emulsion 0.05%,3206732,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Trelegy Ellipta Inhalation Powder,3206733,CDM,637,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Jentadueto XR Oral Tablet ER 5MG-1000,3206734,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Restasis Ophthalmic Emulsion 0.05%,3206735,CDM,637,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Trelegy Ellipta Inhalation Powder,3206736,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Rybelsus Oral Tablet 7MG,3206738,CDM,250,RC,,,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,100.8,
NF-Depakote Delayed-Release Tablet 125MG,3206739,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Prazosin HCl Oral Capsule 1MG,3206740,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-ALPRAZolam Oral Tab ER 0.5MG,3206742,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Remeron Tablet 30MG,3206744,CDM,637,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
"NF-cycloSPORINE, modified Liq Cap 50MG",3206745,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Doxycycline Oral Tablet 100MG,3206748,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-risperiDONE Oral Tablet 0.5MG,3206749,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Sertraline Hydrochloride Oral Tab 25M,3206750,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-TEGretol-XR Oral Tab ER 400MG,3206751,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-Omeprazole Tablet Delayed Release 20M,3206753,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Suboxone Sublingual Film 8MG-2MG,3206759,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Requip XL Oral Tab ER 2MG,3206761,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Baclofen Oral Tablet 5MG,3206763,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-dilTIAZem HCl Tablet 90MG,3206764,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Galantamine HBr Oral Cap ER 8MG,3206765,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Remeron Soltab Dissolve Tablet 45MG,3206766,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Tresiba FlexTouch Pen SubQ Soln 100U/,3206767,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Farxiga Oral Tablet 5MG,3206768,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206769,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Febuxostat Oral Tablet 40MG,3206770,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Vraylar Oral Capsule 3MG,3206772,CDM,250,RC,,,outpatient,,,187,140.25,,149.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.25,149.6,
NF-Prazosin HCl Capsule 5MG,3206773,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Carbinoxamine Maleate Oral Tablet 4MG,3206775,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Inderal LA Oral Cap ER 120MG,3206777,CDM,250,RC,,,outpatient,,,112,84,,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.07,89.6,
NF-Prometrium Oral Liquid Capsule 100MG,3206778,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Ziprasidone HCl Oral Capsule 60MG,3206781,CDM,637,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Exelon TD Patch ER 13.3MG/24HR,3206782,CDM,250,RC,,,outpatient,,,101,75.75,,80.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.64,80.8,
NF-FLUoxetine HCl Oral Tablet 20MG,3206783,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-PHENobarbital Oral Tablet 97.2MG,3206785,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Atenolol/Chlorthalidone Tablet 50MG-2,3206789,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Trelegy Ellipta Inhalation Powder,3206790,CDM,637,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Trelegy Ellipta Inhalation Powder,3206791,CDM,637,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Trelegy Ellipta Inhalation Powder,3206792,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Trelegy Ellipta Inhalation Powder,3206793,CDM,637,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Trelegy Ellipta Inhalation Powder,3206794,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Albuterol Sulfate Inh Soln 1.25MG/3ML,3206795,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Dexilant Delayed-Release Capsule 60MG,3206796,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-busPIRone HCl Oral Tablet 7.5MG,3206798,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Flonase Sensimist Spray 27.5MCG/1Act,3206799,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Hyoscyamine Sulfate Oral Tablet 0.125,3206802,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Amantadine HCl Oral Tablet 100MG,3206803,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Buprenorphine SL Tablet 8MG,3206804,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Daliresp Oral Tablet 250MCG,3206805,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-levETIRAcetam Oral Tablet 250MG,3206807,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-traMADol HCl Oral Cap ER 100MG,3206809,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-Tradjenta Oral Tablet 5MG,3206810,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Nateglinide Oral Tablet 60MG,3206811,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Coenzyme Q10 Capsule 100MG,3206813,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ROBITUSSIN AC 10 ML,3206814,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Acyclovir Oral Tablet 400MG,3206816,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Valium Tablet 10MG,3206818,CDM,637,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3206819,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-cloNIDine HCl Oral Tab ER 0.1MG,3206821,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Lipitor Tablet 80MG,3206822,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-Ranexa Extended-Release Tablet 1000MG,3206823,CDM,250,RC,,,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
NF-Topiramate Oral Capsule 25MG,3206824,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Memantine HCl Oral Capsule ER 28MG,3206825,CDM,637,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Cetirizine Oral Tablet 5MG,3206826,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Methenamine Hippurate 1GM Tablet,3206828,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206830,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206833,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-cloNIDine HCl Oral Tab ER 0.1MG,3206834,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-clonazePAM Tablet 1MG,3206835,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Dulera Inh Aer Pwd 5MCG-100MCG/Act,3206836,CDM,250,RC,,,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.65,84.8,
NF-Cytotec Oral Tablet 100MCG,3206837,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Midodrine HCl Tablet 5MG,3206838,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Xopenex Inh/Neb Soln 0.63MG/3ML,3206839,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Santyl Topical Ointment 250U/1GM,3206841,CDM,637,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
NF-Mirtazapine Tablet 7.5MG,3206843,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Symproic Oral Tablet 0.2MG,3206844,CDM,637,RC,,,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,46.4,
PREDNISONE 2.5 MG TAB,3206845,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Acebutolol HCl Capsule 200MG,3206846,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Acebutolol HCl Capsule 200MG,3206847,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Rasagiline Mesylate Oral Tablet 1MG,3206850,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Rasagiline Mesylate Oral Tablet 0.5MG,3206851,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NICARDIPINE 30 MG CAPSULE,3206853,CDM,637,RC,,,outpatient,,,24.4,18.3,,19.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.82,19.52,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3206854,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Tradjenta Oral Tablet 5MG,3206855,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-NexIUM Capsule 20MG,3206859,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Entresto Oral Tablet 97MG-103MG,3206861,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3206864,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Farxiga Oral Tablet 10MG,3206865,CDM,250,RC,,,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
NF-Breztri Aerosphere Inh Aer Liq,3206866,CDM,250,RC,,,outpatient,,,244,183,,195.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.19,195.2,
NF-CeleBREX Oral Capsule 200MG,3206870,CDM,637,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Inderal LA Oral Cap ER 120MG,3206872,CDM,250,RC,,,outpatient,,,112,84,,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.07,89.6,
NF-Vimovo Delayed Release Tablet 500MG-2,3206873,CDM,250,RC,,,outpatient,,,183,137.25,,146.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.64,146.4,
NF-Lansoprazole Oral Cap DR 15MG,3206874,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Albuterol HFA Inh Aer Pwd 0.09MG/1ACT,3206877,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Mirtazapine Tablet 7.5MG,3206879,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
LVL V OFC VISIT,6299215,CDM,510,RC,99215,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50,224.87,
NF-levocetirizine DiHCl Oral Tablet 5MG,3206881,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Trelegy Ellipta Inhalation Powder,3206884,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-UNITHROID ORAL TABLET 25MCG,3206885,CDM,250,RC,,,outpatient,,,0.89,0.67,,0.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.36,0.71,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3206886,CDM,250,RC,,,outpatient,,,1874,1405.5,,1499.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1030.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1405.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1499.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.1,1499.2,
NF-Tresiba Subcutaneous Solution 100U/1M,3206887,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-ENVARSUS XR TAB ER 4MG,3206888,CDM,250,RC,,,outpatient,,,101.64,76.23,,81.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.9,81.31,
NF-Anastrozole Oral Tablet 1MG,3206889,CDM,250,RC,,,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
NF-Refresh Tears Ophth Solution 0.5%,3206891,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trelegy Ellipta Inhalation Powder,3206892,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Trelegy Ellipta Inhalation Powder,3206895,CDM,250,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
NF-Entresto Oral Tablet 97MG-103MG,3206896,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Linzess Oral Capsule 72MCG,3206900,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-LORazepam Oral Solution 2MG/1ML,3206901,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Morphine Sulfate Oral Solution 20MG/1,3206902,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-NovoLOG Flexpen SubQ Soln 100U/1ML,3206903,CDM,250,RC,,,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,132,
NF-Isosorbide Mononitrate Tablet 10MG,3206904,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Pantoprazole Sodium Oral Tab EC 40MG,3206905,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Lovastatin Tablet 40MG,3206906,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-HCTZ/Triamterene Tablet 25MG-37.5MG,3206907,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Carbidopa/Levodopa Tablet 25MG-100MG,3206908,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Estradiol TD Patch ER 0.05MG/24HR,3206910,CDM,250,RC,,,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
NF-TRULANCE ORAL TABLET 3MG,3206913,CDM,250,RC,,,outpatient,,,69.7,52.28,,55.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.05,55.76,
NF-Linzess Oral Capsule 290MCG,3206915,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3206916,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-oxyCODONE HCl Oral Tab 15MG,3206917,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Celecoxib Oral Capsule 200MG,3206918,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Breztri Aerosphere Inh Aer Liq,3206919,CDM,250,RC,,,outpatient,,,244,183,,195.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.19,195.2,
NF-dilTIAZem HCl Tablet 120MG,3206923,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
AMOXICILLIN ORAL SUSP 400MG/5ML  75 ML,3206924,CDM,636,RC,,,both,,,10.8,8.1,,8.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.35,10.8,
NF-Percocet Oral Tablet 7.5MG-325MG,3206930,CDM,250,RC,,,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.63,76.8,
NF-Trulance Oral Tablet 3MG,3206931,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3206936,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Vascepa Oral Liquid Filled Cap 1GM,3206938,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
TEMAZEPAM 30 MG,3206942,CDM,637,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
NF-Anoro Ellipta Inhalation Powder,3206944,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
BIOFREEZE GEL,3206945,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Haldol Decanoate IM Oil 50MG/1ML,3206946,CDM,250,RC,,,outpatient,,,386,289.5,,308.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.33,308.8,
NF-Invega Sustenna IM Susp ER 234MG,3206947,CDM,250,RC,,,outpatient,,,8702,6526.5,,6961.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3501.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4351,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4351,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4351,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4786.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6961.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3501.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3501.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6961.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6961.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6961.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3501.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6961.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6961.6,
NF-lamoTRIgine Oral Tablet 25MG,3206948,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Loxapine Oral Capsule 10MG,3206949,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-hydroCHLOROthiazide Oral Tablet 12.5M,3206954,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Amitriptyline HCl Tablet 50MG,3206955,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Advair HFA 115/21 Inh Aer 115MCG-21MC,3206956,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Incruse Ellipta Inh Pwd 62.5MCG/1ACT,3206957,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Nuedexta Oral Capsule 20MG-10MG,3206958,CDM,250,RC,,,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.44,78.4,
NF-Synalar Topical Solution 0.01%,3206961,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Movantik Oral Tablet 25MG,3206964,CDM,250,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Anoro Ellipta Inhalation Powder,3206965,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
MUPIROCIN CREAM 2% 30 GM,3206966,CDM,637,RC,,,outpatient,,,420,315,,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,169.01,336,
NF-amLODIPine and Benazepril Cap 10MG-40,3206967,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Propranolol Oral Tablet 60MG,3206968,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-tiZANidine HCl Oral Capsule 2MG,3206969,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
"NF-Vitamin D2 Liquid-Filled Cap 50,000IU",3206970,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-metOLazone Tablet 2.5MG,3206971,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-amLODIPine Besylate/Atorvastatin Calc,3206972,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Famotidine Oral Tablet 40MG,3206973,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Omeprazole Oral Tablet DR 20MG,3206974,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-COLESTIPOL HCL TAB 1GM,3206977,CDM,250,RC,,,outpatient,,,4.58,3.44,,3.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.84,3.66,
NF-Flecainide Acetate Tablet 100MG,3206978,CDM,637,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Rosuvastatin Oral Tablet 40MG,3206980,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Leflunomide Oral Tablet 20MG,3206981,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Abilify Tablet 15MG,3206983,CDM,637,RC,,,outpatient,,,101,75.75,,80.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.64,80.8,
NF-Furosemide Oral Tablet 80MG,3206984,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Pacerone Tablet 100MG,3206988,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Repatha Subcutaneous Solution 140MG/1,3206989,CDM,637,RC,,,outpatient,,,1057,792.75,,845.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,528.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,528.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,528.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,425.34,845.6,
NF-Lokelma PwdforSusp 10GM/1Packet,3206990,CDM,250,RC,,,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.85,83.2,
NF-Sevelamer Carbonate Oral Tablet 800MG,3206991,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Esomeprazole Magnesium Oral Cap DR 20,3206993,CDM,637,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Symtuza Oral Tablet,3206994,CDM,250,RC,,,outpatient,,,601,450.75,,480.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.84,480.8,
NF-IRBESARTAN ORAL TABLET 300MG,3206995,CDM,250,RC,,,outpatient,,,13.66,10.25,,10.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.5,10.93,
NF-Opsumit Oral Tablet 10MG,3206996,CDM,250,RC,,,outpatient,,,1564,1173,,1251.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,782,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,782,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,782,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,860.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,629.35,1251.2,
NF-Dexamethasone Sodium Ophth Solution 0,3206998,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Anoro Ellipta Inhalation Powder,3206999,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-DOFETILIDE CAP 125MCG,3207000,CDM,250,RC,,,outpatient,,,46.38,34.79,,37.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.66,37.1,
NF-Propranolol Hydrochloride Tablet 40MG,3207001,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-dofetilide Oral Capsule 125MCG,3207002,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Visine Dry Eye Relief Ophth Soln 1%,3207003,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Lovastatin Oral Tablet 40MG,3207004,CDM,637,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Fiasp PenFill SubQ Solution 100U/1ML,3207005,CDM,250,RC,,,outpatient,,,159,119.25,,127.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.98,127.2,
NF-dofetilide Oral Capsule 125MCG,3207007,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Visine Dry Eye Relief Ophth Soln 1%,3207009,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Jardiance Oral Tablet 25MG,3207010,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-NovoLOG Inj Soln 100U/1ML,3207011,CDM,637,RC,,,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
NF-Toujeo SubQ Solution 300U/1ML,3207012,CDM,250,RC,,,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,306.4,
NF-Ozempic 1MG Doses SubQ Soln 2MG/1.5ML,3207013,CDM,250,RC,,,outpatient,,,1260,945,,1008,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,507.02,1008,
"NF-Cymbalta Capsule, Delayed Release 30M",3207014,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Tradjenta Oral Tablet 5MG,3207015,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Epipen Kit 0.3MG/0.3ML,3207016,CDM,250,RC,,,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.79,264,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3207017,CDM,250,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Vascepa Oral Liquid Filled Cap 1GM,3207019,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Creon Oral Delayed Release Capsule,3207020,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Januvia Oral Tablet 50MG,3207021,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Budesonide Oral Capsule DR 3MG,3207023,CDM,637,RC,,,outpatient,,,91,68.25,,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.62,72.8,
NF-Probiotic Complex Oral Tablet,3207025,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Pantoprazole Sodium DR Pkt 40MG,3207027,CDM,250,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
NF-NexIUM Capsule 20MG,3207031,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Krill Oil Oral Liquid Capsule 500MG,3207033,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Trulance Oral Tablet 3MG,3207034,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Allegra-D 24 Hour Tab ER 180MG-240MG,3207035,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Estradiol TD Patch ER 0.05MG/24HR,3207037,CDM,250,RC,,,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
NF-Calcium 600 + D3 AvPak Tab 600MG-800I,3207038,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Namzaric Oral Cap ER 14MG-10MG,3207039,CDM,250,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
DEBRIDEMENT OF INFECTED SKIN,6300066,CDM,521,RC,11000,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,1365.74,
NF-Temazepam Capsule 7.5MG,3207044,CDM,250,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
NF-Metoprolol Succinate Tab ER 200MG,3207047,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3207049,CDM,637,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Tudorza Pressair Inh Aer Pwd 400MCG/1,3207050,CDM,637,RC,,,outpatient,,,1268,951,,1014.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,510.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,634,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,634,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,634,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,634,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,697.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1014.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,510.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,510.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1014.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,951,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1014.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1014.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1014.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,510.24,1014.4,
NF-Advair HFA 115/21 Inh Aer 115MCG-21MC,3207052,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Lunesta Tablet 3MG,3207053,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Rybelsus Oral Tablet 3MG,3207054,CDM,250,RC,,,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,100.8,
PER COMP (AGE 05-11),6300110,CDM,972,RC,99393,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.07,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60,115.07,
PER COMP (AGE 12-17),6300111,CDM,972,RC,99394,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,129.71,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,113.5,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60,129.71,
NF-Cephalexin Oral Tablet 500MG,3207059,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
PER COMP (AGE 18-20),6300112,CDM,972,RC,99395,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,134,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,117.25,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60,134,
NF-Albuterol Sulfate Inh Susp 0.09MG/1Ac,3207062,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
"NF-Vitamin D AvPak Liq Cap 1.25MG(50,000",3207064,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Synthroid Tablet 200MCG,3207065,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Capecitabine Avpak Tab 500MG,3207068,CDM,250,RC,,,outpatient,,,157,117.75,,125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.18,125.6,
BEBTELOVIMAB 175 MG VL 2ML,3207070,CDM,636,RC,Q0222,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2394,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2394,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2394,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2394,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,2394,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2394,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,3830.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2394,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3591,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3830.4,
NF-Piroxicam Oral Capsule 20MG,3207071,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Linzess Oral Capsule 290MCG,3207075,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Nortriptyline Oral Capsule 50MG,3207076,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Senokot S Oral Tablet 50MG-8.6MG,3207077,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-hydrALAZINE HCl Tablet 100MG,3207078,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
OCTREOTIDE 500MCG/ML 1ML,3207080,CDM,636,RC,,,both,,,155.5,116.63,,124.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,62.57,155.5,
NF-Ativan Oral Tablet 2MG,3207082,CDM,637,RC,,,outpatient,,,293,219.75,,234.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,117.9,234.4,
NF-Revatio Oral Tablet 20MG,3207083,CDM,637,RC,,,outpatient,,,233,174.75,,186.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,93.76,186.4,
NF-Breztri Aerosphere Inh Aer Liq,3207086,CDM,637,RC,,,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,201.6,
NF-Furosemide Oral Tablet 20MG,3207087,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Furosemide Oral Tablet 40MG,3207088,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Furosemide Oral Tablet 40MG,3207089,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Epipen Kit 0.3MG/0.3ML,3207092,CDM,250,RC,,,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.79,264,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3207093,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Vascepa Oral Liquid Filled Cap 1GM,3207095,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Creon Oral Delayed Release Capsule,3207096,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Jardiance Oral Tablet 25MG,3207097,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Glucosamine Chondroitin 1500 Com Caps,3207100,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Wellbutrin SR 12 Hr Tab ER 150MG,3207104,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Verquvo Oral Tablet 2.5MG,3207106,CDM,250,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3207107,CDM,250,RC,,,outpatient,,,506,379.5,,404.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.61,404.8,
NF-Levocetirizine Dihydrochloride Tab 5M,3207108,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Aldactone Oral Tablet 100MG,3207109,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Medrol DOSEPAK Oral Tablet 4MG,3207110,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-amLODIPine and Benazepril Cap 10MG-40,3207112,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-Tresiba FlexTouch Pen SubQ Soln 100U/,3207115,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Restasis Ophthalmic Emulsion 0.05%,3207117,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3207118,CDM,250,RC,,,outpatient,,,506,379.5,,404.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.61,404.8,
NF-PHENOBARBITAL ORAL TAB 15MG,3207119,CDM,250,RC,,,outpatient,,,1.12,0.84,,0.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.45,0.9,
NF-Farxiga Oral Tablet 10MG,3207121,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Memantine HCl Oral Capsule ER 21MG,3207123,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Linzess Oral Capsule 145MCG,3207127,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-ASPERCREME TOPICAL SOLN 4%,3207129,CDM,250,RC,,,outpatient,,,0.59,0.44,,0.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.24,0.47,
PREV MED NP 40-64,6300115,CDM,521,RC,99386,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207132,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Dexilant Delayed-Release Capsule 60MG,3207133,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Concerta Extended-Release Tablet 36MG,3207134,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Intuniv Oral Extended Release Tablet,3207135,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Oxbryta Oral Tablet 500MG,3207136,CDM,250,RC,,,outpatient,,,513,384.75,,410.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,410.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.43,410.4,
NF-Esomeprazole Mg Capsule DR 20MG,3207137,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Zostrix Cream 0.033%,3207138,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-OxyCONTIN Tablet Extended Release 15M,3207140,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Linzess Oral Capsule 145MCG,3207143,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Linzess Oral Capsule 72MCG,3207144,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Prazosin HCl Oral Capsule 1MG,3207145,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Ingrezza Oral Capsule 40MG,3207146,CDM,637,RC,,,outpatient,,,991,743.25,,792.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,495.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,545.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,398.78,792.8,
NF-RisperDAL Tablet 0.5MG,3207147,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207148,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Ingrezza Oral Capsule 40MG,3207149,CDM,250,RC,,,outpatient,,,991,743.25,,792.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,495.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,545.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,398.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,398.78,792.8,
NF-Cellcept Tablet 500MG,3207150,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3207151,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-NovoLOG SubQ Solution 100U/1ML,3207152,CDM,250,RC,,,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
NF-NovoLOG SubQ Solution 100U/1ML,3207153,CDM,637,RC,,,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
NF-Valium Tablet 10MG,3207154,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Valium Tablet 10MG,3207155,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Valium Tablet 5MG,3207157,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Valium Tablet 5MG,3207158,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Valium Tablet 10MG,3207159,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-metFORMIN ER Oral Tab ER 500MG,3207160,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-metFORMIN ER Oral Tab ER 500MG,3207161,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Pradaxa Oral Capsule 75MG,3207166,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Coenzyme Q10 Oral Liq Cap 200MG,3207167,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Isosorbide Dinitrate Oral Tablet 30MG,3207168,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Crestor Oral Tablet 40MG,3207169,CDM,637,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Complera Oral Tablet 200MG-25MG-300MG,3207170,CDM,250,RC,,,outpatient,,,482,361.5,,385.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,385.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,193.96,385.6,
NURSING HOME ADMIT,6300133,CDM,522,RC,T1015,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-OLANZapine Oral Tablet 2.5MG,3207173,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3207174,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3207175,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Flecainide Acetate Tablet 100MG,3207176,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Restasis Ophthalmic Emulsion 0.05%,3207177,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-FLECAINIDE ACETATE AVPAK TAB 100MG,3207178,CDM,250,RC,,,outpatient,,,22.11,16.58,,17.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.9,17.69,
NF-Invega Oral Extended Release Tablet 6,3207182,CDM,250,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
NF-Flecainide Acetate Tablet 100MG,3207183,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Xeloda Tablet 500MG,3207186,CDM,250,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
NF-Naltrexone Oral Tablet 50MG,3207187,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Anoro Ellipta Inhalation Powder,3207188,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Farxiga Oral Tablet 10MG,3207189,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
COVID VACCINE(DOSE 1)PFIZER  GRAY CAP,3207191,CDM,636,RC,91305,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
COVID VACCINE PFIZER ( DOSE 2) GRAY CAP,3207192,CDM,636,RC,91305,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NEW LEVEL 1 OV,6300181,CDM,510,RC,99201,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207195,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Rexulti Oral Tablet 1MG,3207197,CDM,250,RC,,,outpatient,,,197,147.75,,157.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.27,157.6,
NF-Betamethasone Valerate Cream 0.1%,3207199,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Meclizine Oral Tablet 12.5MG,3207200,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Nizoral Topical Shampoo 2%,3207201,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Flecainide Acetate Tablet 100MG,3207203,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-IRBESARTAN ORAL TABLET 150MG,3207204,CDM,250,RC,,,outpatient,,,11.37,8.53,,9.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.58,9.1,
NF-Biktarvy Oral Tab 50MG-200MG-25MG,3207205,CDM,250,RC,,,outpatient,,,530,397.5,,424,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,213.27,424,
NF-Budesonide Oral Tablet ER 9MG,3207207,CDM,250,RC,,,outpatient,,,238,178.5,,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,95.77,190.4,
NF-Furosemide Oral Tablet 80MG,3207210,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Rexulti Oral Tablet 0.5MG,3207211,CDM,250,RC,,,outpatient,,,197,147.75,,157.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.27,157.6,
NF-APAP/Butalbital/Caffeine/Codeine Caps,3207212,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Tikosyn Oral Capsule 500MCG,3207214,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-BD Insulin Syringes Device,3207215,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Dotti TD Patch ER 0.025MG/24Hr,3207216,CDM,250,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
NF-CoEnyzyme Q10 Oral Cap 100MG,3207217,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Cyanocobalamin Injection 1000MCG/ML,3207218,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Enalapril/HCTZ 10MG-25MG Tablet,3207219,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Terazosin HCl Capsule 10MG,3207220,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-BiDil Oral Tablet 37.5MG-20MG,3207221,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-BEANO CHEWABLE TAB 150U,3207223,CDM,250,RC,,,outpatient,,,0.39,0.29,,0.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.16,0.31,
NF-PHAZYME ULTRA STRENGTH LIQ CAP 180MG,3207224,CDM,250,RC,,,outpatient,,,0.62,0.47,,0.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.25,0.5,
NF-Tradjenta Oral Tablet 5MG,3207226,CDM,250,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Hiprex Tablet 1GM,3207230,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Zithromax Z-Pak Tablet 250MG,3207231,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-SEROquel Tablet 200MG,3207232,CDM,250,RC,,,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,44,
BOTOX 1 UNIT,3207233,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3207238,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3207239,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3207240,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trulance Oral Tablet 3MG,3207241,CDM,250,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
NF-Decadron Oral Tablet 6MG,3207242,CDM,637,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Propranolol Hydrochloride Cap ER 80MG,3207243,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Mirtazapine Tablet 30MG,3207244,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Inderal LA Oral Cap ER 80MG,3207245,CDM,250,RC,,,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
NF-Synjardy XR Oral Tab ER 25MG-1000MG,3207246,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Remeron Tablet 30MG,3207248,CDM,637,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Amiodarone HCl Oral Tablet 100MG,3207249,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
GRISEOFULVIN ORAL SUSP 125MG/5ML(120ML),3207250,CDM,637,RC,,,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,128,
"NF-dilTIAZem HCl Oral Capsule, ER 240MG",3207251,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-tadalafil Oral Tablet 2.5MG,3207253,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
NF-Vitamin D3 Oral Cap 1250MCG,3207254,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-PARoxetine HCl Oral Tablet 30MG,3207255,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Furosemide Oral Tablet 80MG,3207258,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Coenzyme Q-10 Liquid Capsule 200MG,3207259,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Potassium Chloride Oral Tab ER 10MEQ,3207260,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Bethanechol Chloride Oral Tablet 50MG,3207262,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Lithium Carbonate Oral Tab ER 300MG,3207263,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-LORazepam Tablet 2MG,3207264,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-QUEtiapine Fumarate Oral Tablet 200MG,3207265,CDM,637,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-QUEtiapine Fumarate Oral Tablet 400MG,3207266,CDM,637,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Saphris Sublingual Tablet 10MG,3207267,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Trifluoperazine HCl Tablet 5MG,3207268,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Linzess Oral Capsule 72MCG,3207274,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Linzess Oral Capsule 290MCG,3207277,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Morphine Sulfate Oral Solution 20MG/1,3207279,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3207284,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Fenofibrate Oral Tablet 160MG,3207285,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3207287,CDM,250,RC,,,outpatient,,,551,413.25,,440.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,303.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.72,440.8,
NF-Breo Ellipta Inhalation Powder,3207288,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Mirtazapine Oral Tablet 15MG,3207291,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Benazepril Hydrochloride Tablet 20MG,3207292,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Lovaza Oral Liquid Filled Capsule 1GM,3207293,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Alvesco Oral Aerosol Liquid 80MCG/1Ac,3207294,CDM,250,RC,,,outpatient,,,183,137.25,,146.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.64,146.4,
NF-Xigduo XR Oral Tablet ER 10MG-1000MG,3207295,CDM,250,RC,,,outpatient,,,81,60.75,,64.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.8,
NF-Lansoprazole Oral Cap DR 15MG,3207298,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Breztri Aerosphere Inh Aer Liq,3207300,CDM,250,RC,,,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,201.6,
NF-Farxiga Oral Tablet 10MG,3207301,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3207304,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Mexiletine HCl Capsule 150MG,3207305,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Amoxapine Oral Tablet 100mg,3207306,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Amantadine HCl Tablet 100MG,3207307,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Latuda Oral Tablet 80MG,3207308,CDM,250,RC,,,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.08,159.2,
NF-Pioglitazone Hydrochloride TAblet 15M,3207309,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Farxiga Oral Tablet 5MG,3207310,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Entresto Oral Tablet 97MG-103MG,3207311,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Corlanor Oral Tablet 5MG,3207312,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-Vascepa Oral Liquid Filled Cap 0.5GM,3207315,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Lokelma PwdforSusp 10GM/1Packet,3207317,CDM,250,RC,,,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,85.6,
NF-Tradjenta Oral Tablet 5MG,3207318,CDM,250,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Actos Oral Tablet 15MG,3207319,CDM,637,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Tradjenta Oral Tablet 5MG,3207320,CDM,637,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Nystatin Topical Cream 10000U/1 GM,3207321,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-MORPHINE SULFATE CAP ER 30MG,3207322,CDM,250,RC,,,outpatient,,,21.5,16.13,,17.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.65,17.2,
NF-Fexmid Oral Tablet 7.5MG,3207323,CDM,250,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
IND PSYCHOTHERAPY 30 MIN,6300184,CDM,972,RC,90833,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,28.92,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.17,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.17,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.17,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.17,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,28.92,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,28.92,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,61.17,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,61.17,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.92,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,97.87,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,61.17,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.64,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,28.92,97.87,
NF-ARIPiprazole Oral Tablet 10MG,3207326,CDM,637,RC,,,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.48,94.4,
NF-Prazosin HCl Oral Capsule 2MG,3207327,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Trulance Oral Tablet 3MG,3207328,CDM,250,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
NF-Relistor Oral Tablet 150MG,3207330,CDM,250,RC,,,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,85.6,
NF-Cinacalcet Oral Tablet 60MG,3207331,CDM,250,RC,,,outpatient,,,226,169.5,,180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.94,180.8,
NF-Mirtazapine Tablet 15MG,3207332,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-tiZANidine Hydrochloride Oral Tablet,3207333,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Levocetirizine Dihydrochloride Tab 5M,3207334,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Abilify Tablet 10MG,3207335,CDM,637,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-Vitamin D Oral Liq Cap 1.25MG,3207336,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-VASERETIC ORAL TABLET 10MG-25MG,3207338,CDM,250,RC,,,outpatient,,,57.88,43.41,,46.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.29,46.3,
NF-Cardizem Oral Tablet 30MG,3207340,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Fluticasone Furoate/Vilanterol ELLIPT,3207345,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Propranolol Hydrochloride Cap ER 80MG,3207346,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Ala-Hist IR Oral Tablet 2MG,3207347,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Breztri Aerosphere Inh Aer Liq,3207349,CDM,250,RC,,,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,201.6,
NF-Dexilant Delayed-Release Capsule 60MG,3207350,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Linzess Oral Capsule 290MCG,3207351,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Foltx Oral Tablet 2MG-1.13MG-25MG,3207352,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-ISOSOURCE LIQUID,3207353,CDM,250,RC,,,outpatient,,,0.02,0.02,,0.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.02,
NF-Imipramine HCl Tablet 10MG,3207354,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
XR ELBOW 3 VIEWS OR MORE,6900145,CDM,320,RC,73080TC,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Floranex One Cap 200MG-250MG,3207359,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3207360,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3207361,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Linzess Oral Capsule 72MCG,3207367,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Linzess Oral Capsule 72MCG,3207373,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Cosopt Ocumeter Plus Ophth Solution,3207375,CDM,250,RC,,,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,70.4,
NF-Levocetirizine Dihydrochloride Tab 5M,3207376,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Flonase Sensimist Spray 27.5MCG/1Act,3207378,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Fluticasone/Salmeterol Diskus 250/50,3207381,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
ROPINIROLE 0.5 MG,3207382,CDM,637,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
NF-Farxiga Oral Tablet 5MG,3207383,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NP THYROID 60 MG,3207384,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-FLUoxetine HCl Oral Tablet 60MG,3207385,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-Protonix Tablet 40MG,3207386,CDM,637,RC,,,outpatient,,,37,27.75,,29.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.89,29.6,
NF-FLUoxetine HCl Oral Tablet 10MG,3207387,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Midodrine HCl Oral Tablet 5MG,3207389,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Lasix Tablet 80MG,3207391,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3207392,CDM,637,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-Dayvigo Oral Tablet 5MG,3207393,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-BiDil Oral Tablet 37.5MG-20MG,3207395,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-SEROquel Tablet 300MG,3207396,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Fenofibrate Oral Tablet 160MG,3207398,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Metoprolol Tartrate Oral Tablet 75MG,3207400,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Movantik Oral Tablet 25MG,3207401,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Senokot S Oral Tablet 50MG-8.6MG,3207402,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Estrace Vaginal Cream 0.1MG/1GM,3207406,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Estrace Vaginal Cream 0.1MG/1GM,3207407,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3207409,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
GENTAMICIN OINT 0.1% 15 GM,3207410,CDM,637,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
LIDOCIANE JELLY 2% 6ML,3207411,CDM,636,RC,,,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
NF-Linzess Oral Capsule 145MCG,3207412,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Farxiga Oral Tablet 5MG,3207413,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Esomeprazole Mg Capsule DR 40MG,3207414,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207415,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-armodafinil Oral Tablet 50MG,3207416,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Corlanor Oral Tablet 7.5MG,3207417,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Verquvo Oral Tablet 5MG,3207418,CDM,250,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
NF-Alendronate Sod Oral Tablet 10MG,3207419,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-Cinacalcet Oral Tablet 60MG,3207420,CDM,250,RC,,,outpatient,,,226,169.5,,180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.94,180.8,
NF-Esomeprazole Magnesium Oral Cap DR 40,3207421,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Jardiance Oral Tablet 25MG,3207422,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Hiprex Tablet 1GM,3207426,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Invega Sustenna IM Susp ER 156MG,3207429,CDM,250,RC,,,outpatient,,,9172,6879,,7337.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3690.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4586,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4586,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4586,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4586,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5044.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6879,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6879,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6879,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6879,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3690.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3690.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6879,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3690.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7337.6,
NF-Colace Oral Tablet 50MG-8.6MG,3207430,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Trileptal Tablet 300MG,3207432,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Vraylar Oral Capsule 1.5MG,3207433,CDM,250,RC,,,outpatient,,,194,145.5,,155.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.07,155.2,
NF-clonazePAM Tablet 1MG,3207436,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
SUBSEQUENT HOSPITAL CARE LEVEL 1,7000003,CDM,987,RC,99231,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,77.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,68.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,25.81,77.98,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3207438,CDM,250,RC,,,outpatient,,,506,379.5,,404.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,278.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.61,404.8,
NF-Bumetanide Oral Tablet 2MG,3207442,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Lopressor Oral Tablet 50MG,3207444,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Lortab 7.5/325 Oral Tablet 7.5MG-325M,3207445,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Oxybutynin ER Oral Tab ER 15MG,3207446,CDM,637,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Prempro Oral Tablet 0.625MG-5MG,3207449,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Advair HFA 230/21 Inh Aer 230MCG-21MC,3207450,CDM,250,RC,,,outpatient,,,197,147.75,,157.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.27,157.6,
NF-Cinacalcet Hydrochloride Oral Tab 60M,3207451,CDM,250,RC,,,outpatient,,,226,169.5,,180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.94,180.8,
NF-tiZANidine HCl Tablet 2MG,3207452,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Cinacalcet HCl Oral Tablet 60MG,3207453,CDM,250,RC,,,outpatient,,,226,169.5,,180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.94,180.8,
SWING BED SUBSEQUENT-10 MINS,7000028,CDM,982,RC,99307,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,27.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,27.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,27.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,38.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,27.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,60.85,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,38.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,53.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,27.39,60.85,
NF-Movantik Oral Tablet 12.5MG,3207455,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Movantik Oral Tablet 12.5MG,3207457,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Synjardy XR Oral Tab ER 25MG-1000MG,3207458,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Trokendi XR Oral Capsule ER 200MG,3207461,CDM,250,RC,,,outpatient,,,181,135.75,,144.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.83,144.8,
NF-hydrOXYzine Pamoate Oral Capsule 50MG,3207463,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Albuterol Sulfate Inh Soln 1.25MG/3ML,3207464,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Pilocarpine Hydrochloride Tablet 5MG,3207465,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Bumetanide Oral Tablet 2MG,3207467,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-metFORMIN Hydrochloride Tab ER 1000MG,3207468,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Colchicine Oral Capsule 0.6MG,3207470,CDM,637,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-Kerendia Oral Tablet 10MG,3207471,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Nortriptyline Oral Capsule 10MG,3207472,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-NexAVAR Oral Tablet 200MG,3207473,CDM,250,RC,,,outpatient,,,844,633,,675.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,339.63,675.2,
NF-Urinozinc Prostate Plus Oral Tablet,3207474,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Fiasp PenFill SubQ Solution 100U/1ML,3207475,CDM,250,RC,,,outpatient,,,159,119.25,,127.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.98,127.2,
NF-Toujeo Subcutaneous Solution 300U/1ML,3207476,CDM,250,RC,,,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,306.4,
NF-Wellbutrin Oral Tablet 100MG,3207477,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-aMILoride HCl Tablet 5MG,3207478,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Tacrolimus Oral Capsule 1MG,3207479,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Epivir HBV Tablet 100MG,3207480,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Norvir Oral Tablet 100MG,3207481,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Abacavir Oral Tablet 300MG,3207482,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-Prezista Oral Tablet 800MG,3207483,CDM,250,RC,,,outpatient,,,288,216,,230.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.89,230.4,
NF-Alogliptin Benzoate Oral Tablet 6.25M,3207484,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Juluca Oral Tablet 50MG-25MG,3207485,CDM,250,RC,,,outpatient,,,463,347.25,,370.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,231.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,231.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,231.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,231.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,186.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,186.31,370.4,
NF-metFORMIN HCl Oral Tablet ER 1000MG,3207486,CDM,637,RC,,,outpatient,,,444,333,,355.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.67,355.2,
NF-Levothyroxine Oral Tablet 200MCG,3207487,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
"NF-metFORMIN HCl Tab ER, 24HR 500MG",3207488,CDM,637,RC,,,outpatient,,,63,47.25,,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.35,50.4,
NF-Xtandi Oral Tablet 40MG,3207489,CDM,250,RC,,,outpatient,,,481,360.75,,384.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,240.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,193.55,384.8,
NF-Adipex-P Oral Tablet 37.5MG,3207490,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Humana TRUE METRIX Air Meter,3207494,CDM,637,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Humana TRUE METRIX Test Strips,3207495,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trueplus Safety Lancets Device,3207496,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Atorvastatin Calcium Oral Tablet 80MG,3207498,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Tetracycline HCl Oral Capsule 250MG,3207499,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Ubrelvy Oral Tablet 100MG,3207500,CDM,250,RC,,,outpatient,,,416,312,,332.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,167.4,332.8,
NF-Sertraline Oral Tablet 25MG,3207501,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Lovastatin Tablet 40MG,3207505,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BIVALNT CVD VXPFIZR30MCG/0.3ML GRAY CAP,3207506,CDM,636,RC,91312,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
NF-Verquvo Oral Tablet 2.5MG,3207507,CDM,250,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
NF-Prazosin HCl Oral Capsule 1MG,3207508,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Vitamin B12 Injection 1000mcg/ML,3207510,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Probiotic Cap 1Bil CFU,3207512,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Ventolin HFA Inhaler 0.09MG/Inh,3207513,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3207514,CDM,250,RC,,,outpatient,,,506,379.5,,404.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.61,404.8,
"NF-dilTIAZem HCl Oral Capsule, ER 120MG",3207515,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-NovoLOG Flexpen SubQ Soln 100U/1ML,3207516,CDM,637,RC,,,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,132,
NF-Dilaudid Oral Tablet 4MG,3207518,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Entecavir Oral Tablet 1MG,3207519,CDM,250,RC,,,outpatient,,,164,123,,131.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.99,131.2,
NF-Jardiance Oral Tablet 10MG,3207520,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Entresto Oral Tablet 49MG-51MG,3207521,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Fioricet with Codeine Oral Capsule,3207522,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Glucosamine Chondroitin 1500 Com Caps,3207523,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-HydrOXYzine HCl Tablet 50MG,3207524,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Moexipril Tablet 7.5MG,3207525,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CASPOFUNGIN 50 MG,3207529,CDM,636,RC,,,both,,,411.25,308.44,,329,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,329,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,329,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,329,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,165.49,411.25,
ISOVUE 370 75ML,9000842,CDM,270,RC,Q9967,HCPCS,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
NF-Esomeprazole Magnesium Oral Cap DR 40,3207532,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-1-BUTANOL LIQUID,3207535,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-TRAMADOL HCL ORAL TABLET ER 300MG,3207538,CDM,250,RC,,,outpatient,,,40.18,30.14,,32.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.17,32.14,
NF-Levothyroxine Oral Tablet 200MCG,3207539,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-RisperDAL Tablet 3MG,3207541,CDM,637,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
NF-SEROquel Tablet 300MG,3207542,CDM,637,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Sertraline HCl Oral Capsule 200MG,3207543,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
PR US ART DOP-UNILA LOWER EXT - LEFT,41100042,CDM,972,RC,9392626,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-Toprol XL Tablet 200MG,3207545,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Bumetanide Oral Tablet 2MG,3207546,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
OBSERVATION-SUBSEQUENT 15 MINS,70000027,CDM,982,RC,99224,HCPCS,outpatient,,,100,75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,60,60,
NF-Cartia XT Oral 24 Hr Cap ER 300MG,3207549,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Diclofenac Sodium Topical Solution 1.,3207550,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Polytrim Ophth Solution,3207551,CDM,250,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
NF-Oxtellar XR Oral Tab ER 600MG,3207552,CDM,250,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207553,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Dexilant Delayed-Release Capsule 60MG,3207554,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Linzess Oral Capsule 145MCG,3207555,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Trulance Oral Tablet 3MG,3207556,CDM,250,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
NF-Relistor Oral Tablet 150MG,3207558,CDM,250,RC,,,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,85.6,
NF-Tacrolimus Oral Capsule 1MG,3207559,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-aMILoride HCl Tablet 5MG,3207560,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-buPROPion Hydrochloride Tablet 100MG,3207561,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Nurtec ODT Oral Dis Tablet 75MG,3207562,CDM,250,RC,,,outpatient,,,510,382.5,,408,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,205.22,408,
NF-Genteal Ophthalmic Gel 0.25%-0.3%,3207563,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Ozempic 1MG Doses SubQ Soln 4MG/3ML,3207566,CDM,250,RC,,,outpatient,,,1320,990,,1056,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,726,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,531.17,1056,
NF-Tresiba FlexTouch Pen SubQ Soln 100U/,3207568,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
"NF-Epogen Injection 10,000U/ML",3207569,CDM,637,RC,,,outpatient,,,444,333,,355.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.67,355.2,
NF-Venlafaxine HCl Oral Capsule ER 37.5M,3207571,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Percocet Oral Tablet 7.5MG-325MG,3207572,CDM,250,RC,,,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.25,84,
NF-Kerendia Oral Tablet 10MG,3207573,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
"NF-K-Tab Oral Tablet, Extended Release 8",3207574,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Mitigare Oral Capsule 0.6MG,3207575,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Entresto Oral Tablet 97MG-103MG,3207576,CDM,637,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Prazosin Oral Capsule 2MG,3207577,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Amitriptyline HCl Oral Tablet 50MG,3207579,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Breztri Aerosphere Inh Aer Liq,3207580,CDM,250,RC,,,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,201.6,
NF-Kerendia Oral Tablet 10MG,3207581,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Linzess Oral Capsule 290MCG,3207583,CDM,250,RC,,,outpatient,,,72,54,,57.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.97,57.6,
NF-Fludrocortisone Acetate Tablet 0.1MG,3207584,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Lovaza Oral Liquid Filled Capsule 1GM,3207585,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-Tradjenta Oral Tablet 5MG,3207586,CDM,250,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Cialis Tablet 20MG,3207587,CDM,250,RC,,,outpatient,,,308,231,,246.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,154,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,154,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.94,246.4,
NF-Mirtazapine Tablet 15MG,3207588,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Tresiba Subcutaneous Solution 100U/1M,3207589,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-MOUNJARO SUBQ SOLN 5MG/0.5ML,3207590,CDM,250,RC,,,outpatient,,,2163.02,1622.27,,1730.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,870.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1081.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1081.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1081.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1189.66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1730.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,870.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,870.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1730.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1622.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1730.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1730.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,870.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1730.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,870.4,1730.42,
NF-Lunesta Tablet 3MG,3207595,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Ubrelvy Oral Tablet 50MG,3207596,CDM,250,RC,,,outpatient,,,416,312,,332.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,167.4,332.8,
NF-Methadone Oral Tablet 10MG,3207597,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Lunesta Tablet 3MG,3207603,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Vitamin D Oral Capsule 50000IU,3207604,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Ozempic 2MG Doses SubQ Soln 8MG/3ML,3207605,CDM,250,RC,,,outpatient,,,1320,990,,1056,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,726,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,531.17,1056,
NF-Tylenol w/Codeine #3 Tablet 300MG-30M,3207606,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Jardiance Oral Tablet 10MG,3207607,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Synjardy XR Oral Tab ER 25MG-1000MG,3207608,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-dilTIAZem HCl ER Oral Cap ER 180MG,3207609,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Amoxicillin Tablet 500MG,3207610,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Methylphenidate HCl Oral Tablet ER 18,3207611,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-Sertraline Hydrochloride Tablet 25MG,3207612,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Memantine HCl Oral Capsule ER 14MG,3207613,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Propranolol HCl Tablet 40MG,3207614,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Rasagiline Oral Tablet 1MG,3207615,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Ingrezza Oral Capsule 60MG,3207616,CDM,250,RC,,,outpatient,,,1089,816.75,,871.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,438.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,871.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,438.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,871.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,871.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,438.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,438.21,871.2,
NF-risperiDONE Oral Tablet 0.5MG,3207617,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Pepcid Oral Tablet 40MG,3207618,CDM,637,RC,,,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,65.6,
NF-Ofloxacin Ophthalmic Solution 0.3%,3207619,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-PROPRANOLOL HCL AVPAK TABLET 40MG,3207620,CDM,250,RC,,,outpatient,,,2.41,1.81,,1.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.93,
NF-Breztri Aerosphere Inh Aer Liq,3207621,CDM,250,RC,,,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,201.6,
NF-Systane Ophth Solution,3207622,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Prevagen Oral Cap 10MG-50MCG,3207623,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Uptravi Oral Tablet 1600MCG,3207624,CDM,250,RC,,,outpatient,,,1564,1173,,1251.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,782,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,782,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,782,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,860.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,629.35,1251.2,
PLAN B ONE STEP,3207625,CDM,637,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NALOXONE NASAL SPRAY 4 MG,3207626,CDM,636,RC,,,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
NF-Memantine HCl Oral Capsule ER 14MG,3207628,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Propranolol HCl Tablet 40MG,3207629,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Rasagiline Oral Tablet 1MG,3207630,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Jardiance Oral Tablet 25MG,3207632,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207633,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Farxiga Oral Tablet 10MG,3207634,CDM,250,RC,,,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
NF-amLODIPine/Benazepril HCl Cap 10MG-40,3207635,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3207636,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
MILK OF MAG 30 ML,3207637,CDM,637,RC,,,outpatient,,,1.6,1.2,,1.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.64,1.28,
NF-Esomeprazole Magnesium Capsule DR 40M,3207638,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Estrace Vaginal Cream 0.1MG/1GM,3207639,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Anoro Ellipta Inhalation Powder,3207640,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Pilocarpine HCl Oral Tablet 5MG,3207641,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Sertraline HCl Oral Capsule 150MG,3207642,CDM,250,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Lyrica Oral Capsule 200MG,3207643,CDM,637,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3207644,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
NF-Breztri Aerosphere Inh Aer Liq,3207645,CDM,250,RC,,,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,201.6,
NF-Vraylar Oral Capsule 3MG,3207646,CDM,250,RC,,,outpatient,,,194,145.5,,155.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.07,155.2,
NF-NovoLOG SubQ Solution 100U/1ML,3207647,CDM,250,RC,,,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
NF-ZyPREXA Tablet 10MG,3207649,CDM,637,RC,,,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.04,81.6,
NF-Tresiba Subcutaneous Solution 100U/1M,3207652,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NF-Bisoprolol Fumarate Tablet 5MG,3207653,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Tadalafil Oral Tablet 20MG,3207654,CDM,250,RC,,,outpatient,,,281,210.75,,224.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,113.07,224.8,
NF-PRAZOSIN HCL CAP 1MG,3207655,CDM,250,RC,,,outpatient,,,6.56,4.92,,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.64,5.25,
NF-TADALAFIL ORAL TABLET 20MG,3207656,CDM,250,RC,,,outpatient,,,281.76,211.32,,225.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,113.38,225.41,
NF-Albuterol Sulfate Inh Susp 0.09MG/1Ac,3207657,CDM,637,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Florastor Oral Capsule 250MG,3207659,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-NexAVAR Oral Tablet 200MG,3207660,CDM,250,RC,,,outpatient,,,844,633,,675.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,339.63,675.2,
NF-Esomeprazole Magnesium Cap DR 20MG,3207661,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-Rasagiline Mesylate Oral Tablet 1MG,3207662,CDM,250,RC,,,outpatient,,,92,69,,73.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.02,73.6,
NF-Ozempic 2MG Doses SubQ Soln 8MG/3ML,3207663,CDM,250,RC,,,outpatient,,,1320,990,,1056,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,726,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,990,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,531.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,531.17,1056,
NF-Provera Oral Tablet 5MG,3207664,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Adderall Oral Tablet 20MG,3207665,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-ARIPiprazole Oral Tablet 10MG,3207666,CDM,637,RC,,,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.48,94.4,
"NF-CoQ10 Oral Capsule, Liquid Filled 200",3207667,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Rocklatan Ophth Soln 0.02%-0.005%,3207668,CDM,250,RC,,,outpatient,,,558,418.5,,446.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,279,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,279,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,224.54,446.4,
NF-Mupirocin Ointment 2%,3207670,CDM,637,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3207671,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Creon Oral Cap DR 24000U-76000U-12000,3207672,CDM,250,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Epipen Kit 0.3MG/0.3ML,3207673,CDM,250,RC,,,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,181.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.79,264,
NF-Vascepa Oral Liquid Filled Cap 1GM,3207675,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Jardiance Oral Tablet 25MG,3207676,CDM,250,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
NF-Acidophilus Oral Tab 1Billion U,3207677,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Clarithromycin Oral Tablet 250MG,3207678,CDM,637,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Cardizem Tablet 120MG,3207679,CDM,637,RC,,,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,65.6,
NF-Verquvo Oral Tablet 10MG,3207681,CDM,250,RC,,,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,76,
NF-Griseofulvin Oral Tablet 500MG,3207682,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Oxtellar XR Oral Tab ER 600MG,3207683,CDM,250,RC,,,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.63,76.8,
NF-Rayaldee Oral Cap ER 30MCG,3207684,CDM,250,RC,,,outpatient,,,174,130.5,,139.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.02,139.2,
NF-Advair HFA 230/21 Inh Aer 230MCG-21MC,3207685,CDM,250,RC,,,outpatient,,,197,147.75,,157.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.27,157.6,
NF-Ketoconazole Tablet 200MG,3207686,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Prempro Oral Tablet 0.625MG-5MG,3207687,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
LORTAB ELIXIR 10MG/300MG /15ML,3207690,CDM,636,RC,,,both,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,27,
NF-Ofirmev Intravenous Solution 10MG/1ML,3207692,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Combivent Respimat Inhalation Spray,3207693,CDM,637,RC,,,outpatient,,,527,395.25,,421.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,289.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,212.06,421.6,
NF-Temazepam Capsule 30MG,3207696,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207697,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Verquvo Oral Tablet 2.5MG,3207698,CDM,250,RC,,,outpatient,,,95,71.25,,76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.23,76,
NF-Metoprolol Succinate Tab ER 200MG,3207700,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3207702,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
CEFDINIR SUSPENSION 125MG/5ML 60 ML,3207703,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Adderall Oral Tablet 10MG,3207707,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Lyrica Oral Capsule 150MG,3207708,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Suboxone Sublingual Film 8MG-2MG,3207709,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-buPROPion HCl Tab ER 150MG,3207711,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-risperiDONE Oral Tablet 4MG,3207713,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Jardiance Oral Tablet 25MG,3207715,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Levocetirizine Dihydrochloride Tab 5M,3207716,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Mounjaro SubQ Soln 5MG/0.5ML,3207717,CDM,250,RC,,,outpatient,,,2271,1703.25,,1816.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1249.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,913.85,1816.8,
NF-NexIUM Oral Delayed-Release Capsule 2,3207718,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
NF-Jardiance Oral Tablet 25MG,3207720,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Naltrexone Oral Tablet 50MG,3207721,CDM,250,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Enbrel Subcutaneous Solution 25MG/0.5,3207722,CDM,250,RC,,,outpatient,,,7824,5868,,6259.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3148.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3912,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3912,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3912,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3912,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4303.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5868,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5868,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5868,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5868,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3148.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3148.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5868,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3148.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6259.2,
RABEPRAZOLE SOD DR 20 MG,3207723,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3207724,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3207725,CDM,250,RC,,,outpatient,,,568,426,,454.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,228.56,454.4,
NF-Dexilant Delayed-Release Capsule 60MG,3207727,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-dilTIAZem Oral Cap ER 240MG,3207729,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Asmanex HFA Inh Aer Powder 100MCG/1AC,3207730,CDM,250,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NF-clonazePAM Oral Tablet 1MG,3207731,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Flovent Diskus Inh/Neb Pwd 250MCG/1AC,3207732,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Vraylar Oral Capsule 3MG,3207733,CDM,250,RC,,,outpatient,,,203,152.25,,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,81.69,162.4,
NF-Jardiance Oral Tablet 25MG,3207736,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Toujeo Subcutaneous Solution 300U/1ML,3207737,CDM,250,RC,,,outpatient,,,402,301.5,,321.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,161.76,321.6,
NF-Trulicity SubQ Soln 4.5MG/0.5ML,3207738,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Wellbutrin SR 12 Hr Tab ER 150MG,3207739,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Glyxambi Oral Tablet 10MG-5MG,3207740,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Morphine Sulfate Tablet ER 60MG,3207743,CDM,637,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
NF-Desmopressin Acetate Oral Tablet 0.1M,3207744,CDM,250,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
KETOCONAZOLE 200  MG TAB,3207745,CDM,636,RC,,,both,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.5,
NF-Breztri Aerosphere Inh Aer Liq,3207746,CDM,250,RC,,,outpatient,,,259,194.25,,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.22,207.2,
NF-Digoxin Oral Tablet 0.0625MG,3207747,CDM,637,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Loratadine-D 24Hr Tab ER 10MG-240MG,3207748,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Selegiline HCl Tablet 5MG,3207749,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
DEXTROSE 5% 50 ML,3207750,CDM,636,RC,,,both,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,16.5,
NF-Restasis Ophthalmic Emulsion 0.05%,3207751,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Esomeprazole Magnesium Oral Cap DR 20,3207752,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
LOVENOX 30MG INJ,3200513,CDM,636,RC,J1650,HCPCS,both,,,100.25,75.19,,80.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.34,100.25,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3207757,CDM,250,RC,,,outpatient,,,521,390.75,,416.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,209.65,416.8,
NF-Trulance Oral Tablet 3MG,3207758,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Breo Ellipta Inh Pwd 100MCG/1Actuatio,3207760,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Alendronate Sod Oral Tablet 35MG,3207761,CDM,637,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Nortriptyline Hydrochloride Cap 50MG,3207762,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Lovaza Oral Liquid Filled Capsule 1GM,3207763,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Labetalol HCl Tablet 300MG,3207764,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
WASHER,890228,CDM,278,RC,C1713,HCPCS,both,,,100.4,75.3,,80.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.4,869.4,
NF-metOLazone Tablet 10MG,3207766,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Rybelsus Oral Tablet 7MG,3207767,CDM,637,RC,,,outpatient,,,138,103.5,,110.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55.53,110.4,
NF-Leflunomide Oral Tablet 20MG,3207772,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Enalapril/HCTZ 10MG-25MG Tablet,3207774,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Desmopressin Acetate Oral Tablet 0.2M,3207776,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Adderall Oral Tablet 10MG,3207777,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Adderall Oral Tablet 20MG,3207778,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Jardiance Oral Tablet 25MG,3207779,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Trulicity SubQ Soln 4.5MG/0.5ML,3207780,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Cosopt Ocumeter Plus Ophth Solution,3207781,CDM,250,RC,,,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
NF-Levocetirizine Dihydrochloride Tab 5M,3207782,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Jardiance Oral Tablet 10MG,3207783,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Bactroban Ointment 2%,3207784,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Mexiletine HCl Capsule 150MG,3207786,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-MEXILETINE HCL CAP 150MG,3207787,CDM,250,RC,,,outpatient,,,3.35,2.51,,2.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,2.68,
NF-Mexiletine HCl Capsule 150MG,3207788,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Vimpat Oral Tablet 100MG,3207789,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Cholestyramine PwdSusp 4GM/1PKT,3207790,CDM,637,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Sildenafil Tablet 100MG,3207792,CDM,250,RC,,,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
NF-Omega-3-Acid Ethyl Esters Liq Cap 1GM,3207793,CDM,637,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-Linzess Oral Capsule 290MCG,3207794,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Prazosin HCl Capsule 1MG,3207795,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Suboxone Sublingual Film 8MG-2MG,3207796,CDM,250,RC,,,outpatient,,,39,29.25,,31.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,31.2,
NF-Rosuvastatin Oral Tablet 5MG,3207799,CDM,637,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
NF-Ondansetron Disintegrating Tablet 4MG,3207800,CDM,637,RC,,,outpatient,,,82,61.5,,65.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,65.6,
NF-Jakafi Oral Tablet 5MG,3207801,CDM,250,RC,,,outpatient,,,1234,925.5,,987.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,496.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,617,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,617,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,617,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,617,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,987.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,496.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,987.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,925.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,987.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,987.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,496.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,987.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,496.56,987.2,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3207802,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-LOVAZA LIQ CAP 1GM,3207803,CDM,250,RC,,,outpatient,,,6.88,5.16,,5.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,5.5,
NF-CeleBREX Oral Capsule 200MG,3207804,CDM,637,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Flecainide Acetate Oral Tablet 150MG,3207805,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Jardiance Oral Tablet 25MG,3207808,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NP THYROID 30 MG,3207809,CDM,636,RC,,,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
NF-AIRBORNE ELDERBERRY ORAL CHEW TAB,3207810,CDM,250,RC,,,outpatient,,,1.72,1.29,,1.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.69,1.38,
NF-carBAMazepine Oral Cap ER 200MG,3207812,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Venlafaxine Hydrochloride Tablet 37.5,3207816,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-ZyPREXA Tablet 15MG,3207817,CDM,250,RC,,,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
NF-ALPRAZolam Tablet 2MG,3207818,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-CLINIMIX E 5/20 IV SOLN,3207820,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-CLINIMIX E 5/20 IV SOLUTION,3207821,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
NF-CLINIMIX IV SOLN 5%-20%,3207822,CDM,250,RC,,,outpatient,,,0.2,0.15,,0.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.08,0.16,
CLINIMIX 5/20 1000ML,3207823,CDM,636,RC,,,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
NF-Warfarin Sodium Tablet 6MG,3207824,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Ritalin Tablet 20MG,3207825,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Acyclovir Oral Tablet 400MG,3207826,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Pregabalin Oral Cap 150MG,3207827,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Rybelsus Oral Tablet 14MG,3207828,CDM,250,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
NF-Alogliptin Benzoate Oral Tablet 6.25M,3207829,CDM,250,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Febuxostat Oral Tablet 40MG,3207830,CDM,250,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
CHLORDIAZEPOXIDE SERUM,2800937,CDM,301,RC,80150,HCPCS,outpatient,,,101,75.75,,80.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,55.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,80.8,
NF-Omeprazole Delayed-Release Capsule 40,3207834,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-Butalbital-Acetaminophen-Caffeine Cap,3207836,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Glyxambi Oral Tablet 25MG-5MG,3207837,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Letrozole Oral Tablet 2.5MG,3207838,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3207839,CDM,250,RC,,,outpatient,,,568,426,,454.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,228.56,454.4,
NF-Linzess Oral Capsule 290MCG,3207840,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Entresto Oral Tablet 49MG-51MG,3207841,CDM,637,RC,,,outpatient,,,49,36.75,,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.72,39.2,
NF-LaMICtal Oral Tablet 25MG,3207842,CDM,250,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
NF-Buprenorphine-Naloxone SL Film 8MG-2M,3207843,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-oxyBUTYnin Chloride Tab ER 15MG,3207844,CDM,637,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-hydrOXYzine Pamoate Capsule 100MG,3207845,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Prazosin HCl Capsule 1MG,3207847,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Prazosin HCl Capsule 2MG,3207848,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Synjardy Oral Tablet 12.5MG-500MG,3207849,CDM,250,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
RID MAX LICE REMOVAL KIT,3207850,CDM,636,RC,,,both,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,30,
NF-Creon Oral Delayed Release Capsule,3207851,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Coenzyme Q10 Capsule 100MG,3207852,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Dexilant Delayed-Release Capsule 60MG,3207853,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NEG PRESSURE WOUND TX >50,6200216,CDM,360,RC,97606,HCPCS,outpatient,,,101,75.75,,80.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,201.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,201.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.64,551.37,
NF-Megestrol Acetate Tablet 20MG,3207856,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Glyxambi Oral Tablet 10MG-5MG,3207858,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac,3207859,CDM,250,RC,,,outpatient,,,568,426,,454.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,228.56,454.4,
NF-Breztri Aerosphere Inh Aer Liq,3207861,CDM,250,RC,,,outpatient,,,259,194.25,,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.22,207.2,
LACTULOSE 10G/15ML 473ML (FOR ENEMA),3207862,CDM,636,RC,,,both,,,20.5,15.38,,16.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.25,20.5,
NF-GAMMAPLEX 10% IV SOLN 100MG/1ML,3207863,CDM,250,RC,,,outpatient,,,91.21,68.41,,72.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.7,72.97,
NF-Letrozole Oral Tablet 2.5MG,3207864,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3207866,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
ER EA ADD'L IV INJ THERAPEUTIC/DIAG,1400260,CDM,260,RC,96375,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.54,81.6,
NF-Austedo Oral Tablet 9MG,3207869,CDM,250,RC,,,outpatient,,,392,294,,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,157.74,313.6,
NF-Ferrous Sulfate Tablet 325mg,3207870,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Flecainide Acetate Oral Tablet 100MG,3207871,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Namenda XROral Capsule ER 28MG,3207872,CDM,250,RC,,,outpatient,,,68,51,,54.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.36,54.4,
NF-Nuplazid Oral Capsule 34MG,3207873,CDM,250,RC,,,outpatient,,,675,506.25,,540,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,337.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,371.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,271.62,540,
NF-Abilify Oral Tablet 2MG,3207876,CDM,250,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
NF-EXELON CAPSULE 4.5MG,3207877,CDM,250,RC,,,outpatient,,,12.72,9.54,,10.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.12,10.18,
NF-Prevacid Delayed-Release Capsule 15MG,3207878,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3207881,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-metOLazone Oral Tablet 10MG,3207883,CDM,637,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Jardiance Oral Tablet 10MG,3207885,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Mexiletine HCl Capsule 150MG,3207886,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Novaplus Tacrolimus Oral Capsule 0.5M,3207889,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Flovent Inhaler 0.22MG/Inh,3207890,CDM,250,RC,,,outpatient,,,152,114,,121.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.16,121.6,
NF-Pradaxa Oral Capsule 75MG,3207891,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3207892,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Muro-128 Ophth Solution 2%,3207893,CDM,637,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Jardiance Oral Tablet 25MG,3207894,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Tradjenta Oral Tablet 5MG,3207895,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-lamoTRIgine Oral Tablet 200MG,3207897,CDM,637,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Farxiga Oral Tablet 10MG,3207899,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-glyBURIDE/metFORMIN HCl Oral Tablet,3207900,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-hydrOXYzine HCl Oral Tablet 50MG,3207903,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Jardiance Oral Tablet 10MG,3207904,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Vimpat Oral Tablet 100MG,3207906,CDM,250,RC,,,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
NF-Ozempic SubQ Soln 2MG/3ML,3207908,CDM,250,RC,,,outpatient,,,1384,1038,,1107.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,761.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,556.92,1107.2,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3207909,CDM,250,RC,,,outpatient,,,521,390.75,,416.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,209.65,416.8,
NF-Acyclovir Oral Tablet 400MG,3207910,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Fluocinolone Acetonide Topical Oil 0.,3207911,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Risedronate Sodium Oral Tablet 150MG,3207912,CDM,250,RC,,,outpatient,,,862,646.5,,689.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,346.87,689.6,
NF-Humira Subcutaneous Solution 40MG/0.4,3207913,CDM,250,RC,,,outpatient,,,15368,11526,,12294.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6184.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7684,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7684,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7684,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7684,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8452.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11526,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11526,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11526,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11526,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6184.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6184.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11526,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6184.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12294.4,
NF-Torsemide Oral Tablet 100mg,3207915,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Isosorbide Dinitrate Tablet 5MG,3207916,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-metOLazone Tablet 2.5MG,3207917,CDM,637,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NSS 50 ML,3207918,CDM,250,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Yupelri Inhalation Solution 175MCG/3M,3207919,CDM,637,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
NF-Linzess Oral Capsule 72MCG,3207923,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Progesterone Oral Capsule 200MG,3207925,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-Fenofibrate Oral Tablet 48MG,3207928,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Bisoprolol Fumarate Tablet 10MG,3207929,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Slow Fe Oral Tablet 45MG,3207930,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Colace Oral Tablet 50MG-8.6MG,3207932,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
ASSAY OF PORPHOBILINOGEN 24 HR,2800096,CDM,305,RC,84110,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.22,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.22,81.6,
NF-Cyclobenzaprine HCL Oral Tablet 5MG,3207936,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Trulicity SubQ Solution 0.75MG/0.5ML,3207937,CDM,250,RC,,,outpatient,,,2066,1549.5,,1652.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1136.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,831.36,1652.8,
CARMEX .35 OZ TUBE,3207938,CDM,637,RC,,,outpatient,,,1.89,1.42,,1.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.76,1.51,
NF-Ozempic SubQ Soln 2MG/3ML,3207939,CDM,250,RC,,,outpatient,,,1384,1038,,1107.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,761.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1038,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,556.92,1107.2,
NF-Tresiba Subcutaneous Solution 100U/1M,3207943,CDM,250,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
Isentress 400 MG,3207946,CDM,636,RC,,,both,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,75,
NF-Nystatin Powder,3207949,CDM,637,RC,,,outpatient,,,514,385.5,,411.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,257,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,257,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,257,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,257,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.83,411.2,
NF-Foltanx Oral Tablet 3MG-35MG-2MG,3207950,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Linzess Oral Capsule 145MCG,3207951,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Concerta Extended-Release Tablet 54MG,3207952,CDM,250,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
NF-LaMICtal XR Extended Release Tab 100M,3207953,CDM,250,RC,,,outpatient,,,133,99.75,,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.52,106.4,
NF-Requip XL Oral Tab ER 2MG,3207954,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Requip XL Oral Tab ER 2MG,3207955,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-REQUIP XL ORAL TAB ER 12MG,3207956,CDM,250,RC,,,outpatient,,,109.3,81.98,,87.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.98,87.44,
NF-Fluticasone/Salmeterol 100/50,3207957,CDM,637,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-Combivent Respimat Inhalation Spray,3207959,CDM,250,RC,,,outpatient,,,527,395.25,,421.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,289.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,212.06,421.6,
NF-amLODIPine/Benazepril HCl Cap 5MG-40M,3207962,CDM,637,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-PriLOSEC Oral Packet 10MG/1Pkt,3207963,CDM,637,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Eplerenone Oral Tablet 50MG,3207964,CDM,637,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Vraylar Oral Capsule 1.5MG,3207965,CDM,250,RC,,,outpatient,,,203,152.25,,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,81.69,162.4,
NF-Vraylar Oral Capsule 1.5MG,3207966,CDM,637,RC,,,outpatient,,,203,152.25,,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,81.69,162.4,
NF-guanFACINE HCl Oral Tab ER 3MG,3207967,CDM,250,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-Adderall XR Oral Cap ER 20MG,3207968,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Focalin XR Extended-Release Cap 10MG,3207970,CDM,637,RC,,,outpatient,,,61,45.75,,48.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.55,48.8,
NF-Mycophenolate Mofetil Tablet 500MG,3207971,CDM,637,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-QUEtiapine Oral Tablet 200MG,3207972,CDM,637,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Novolin N FlexPen SubQ Susp 100U/1ML,3207973,CDM,637,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Pacerone Tablet 100MG,3207974,CDM,637,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
NF-1-BUTANOL LIQUID,3207976,CDM,250,RC,,,outpatient,,,0.04,0.03,,0.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.02,0.03,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3207977,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-DAPTOmycin IV Pwd for Soln 500MG,3207981,CDM,250,RC,,,outpatient,,,1977,1482.75,,1581.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1087.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,795.54,1581.6,
NF-DAPTOMYCIN IV PWD FOR SOLN 500MG,3207982,CDM,250,RC,,,outpatient,,,1977.98,1483.49,,1582.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,988.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1087.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1582.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,795.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1582.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1483.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1582.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1582.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1582.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,795.94,1582.38,
NF-ALTAVERA ORAL TABLET 0.15MG-30MCG,3207983,CDM,250,RC,,,outpatient,,,4.09,3.07,,3.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.65,3.27,
NF-Farxiga Oral Tablet 5MG,3207984,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Probiotic Colon Care Oral Capsule,3207985,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DAPTOMYCIN 500 MG,3207987,CDM,636,RC,,,both,,,216,162,,172.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,118.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.92,216,
NF-DAPTOMYCIN IV PWD FOR SOLN 500MG,3207988,CDM,250,RC,,,outpatient,,,82.55,61.91,,66.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.22,66.04,
NF-Farxiga Oral Tablet 10MG,3207991,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Methotrexate Oral Tablet 2.5MG,3207992,CDM,250,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
NF-prednisoLONE Sodium pH Ophth Solution,3207994,CDM,250,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NF-True Metrix Glucose Meter Device,3207996,CDM,637,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-True Metrix Self Monitoring Strips,3207997,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-BD Insulin Syringes BD Ultra-Fine Nee,3207998,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Levocetirizine Dihydrochloride Tab 5M,3208000,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-ReliOn Confirm/Micro Test Strips Devi,3208001,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Betamethasone Diprop-Clotr Lot 0.05%-,3208002,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
NF-Estradiol Vaginal Cream 0.1MG/1GM,3208003,CDM,250,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-quiNIDine Sulfate Tablet 200MG,3208004,CDM,250,RC,,,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,44,
NF-Accu-Chek Guide Test Strips Device,3208005,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-One Touch Test Strips,3208006,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Methotrexate Oral Tablet 2.5MG,3208009,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Gimoti Nasal Spray 15MG/1ACT,3208010,CDM,250,RC,,,outpatient,,,898,673.5,,718.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,361.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,449,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,449,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,449,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,449,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,493.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,361.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,673.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,718.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,361.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,361.36,718.4,
NF-Nurtec ODT Oral Dis Tablet 75MG,3208011,CDM,250,RC,,,outpatient,,,528,396,,422.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,290.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,212.47,422.4,
NF-Xyzal Allergy 24HR Oral Tablet 5MG,3208013,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Renvela Oral Tablet 800MG,3208015,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Renvela Oral Tablet 800MG,3208016,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Methotrexate Oral Tablet 2.5MG,3208017,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3208018,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Jardiance Oral Tablet 10MG,3208019,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Jardiance Oral Tablet 10MG,3208020,CDM,637,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Warfarin Sodium Tablet 6MG,3208021,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-NexIUM Capsule 40MG,3208023,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
LAMOTRIGINE 25 MG,3208024,CDM,636,RC,,,both,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,8,
NF-levETIRAcetam Oral Tablet 750MG,3208026,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-BD Test Strips Device,3208027,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Blood GLucose Monitoring System,3208028,CDM,637,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Methylphenidate Oral Tablet 20MG,3208032,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Norethindrone Oral Tablet 0.35MG,3208033,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Proventil HFA Inh Susp 0.09MG/1Act,3208034,CDM,637,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-CLONAZEPAM DISINTEGRATING TAB 0.125MG,3208036,CDM,250,RC,,,outpatient,,,4.81,3.61,,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.94,3.85,
NF-Linzess Oral Capsule 72MCG,3208037,CDM,637,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Linzess Oral Capsule 72MCG,3208038,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Letrozole Oral Tablet 2.5MG,3208039,CDM,250,RC,,,outpatient,,,67,50.25,,53.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.96,53.6,
NF-OLANZapine Oral Tablet 10MG,3208040,CDM,637,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-Rexulti Oral Tablet 0.5MG,3208041,CDM,250,RC,,,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act,3208042,CDM,250,RC,,,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.08,93.6,
NF-Motegrity Oral Tablet 2MG,3208044,CDM,250,RC,,,outpatient,,,74,55.5,,59.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.78,59.2,
NF-Xigduo XR Oral Tablet ER 5MG-500MG,3208046,CDM,250,RC,,,outpatient,,,83,62.25,,66.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.4,66.4,
NF-Biktarvy Oral Tab 50MG-200MG-25MG,3208048,CDM,250,RC,,,outpatient,,,561,420.75,,448.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,308.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,225.75,448.8,
NF-Pregabalin Oral Cap 150MG,3208049,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Trulicity SubQ Soln 3MG/0.5ML,3208050,CDM,250,RC,,,outpatient,,,2066,1549.5,,1652.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1033,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1136.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,831.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,831.36,1652.8,
NF-Fluocinolone Acetonide Topical Oil 0.,3208055,CDM,250,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
NF-Mometasone Furoate Ointment 0.1%,3208056,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Risedronate Sodium Oral Tablet 150MG,3208057,CDM,250,RC,,,outpatient,,,862,646.5,,689.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,646.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,346.87,689.6,
NF-Breztri Aerosphere Inh Aer Liq,3208058,CDM,250,RC,,,outpatient,,,259,194.25,,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.22,207.2,
NF-ProAir RespiClick Inh Powder 0.09MG/1,3208060,CDM,250,RC,,,outpatient,,,302,226.5,,241.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.52,241.6,
NF-clonazePAM Tablet 1MG,3208062,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Rybelsus Oral Tablet 3MG,3208063,CDM,250,RC,,,outpatient,,,138,103.5,,110.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55.53,110.4,
NF-Spiriva Respimat Inh Spray 1.25MCG/1A,3208064,CDM,250,RC,,,outpatient,,,568,426,,454.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,228.56,454.4,
NF-Breo Ellipta Inhalation Powder,3208065,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
ESCITALOPRAM 5 MG,3208067,CDM,636,RC,,,both,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,5,
NF-amLODIPine-valsartan Tab 10MG-320MG,3208068,CDM,250,RC,,,outpatient,,,29,21.75,,23.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.67,23.2,
NF-Fluocinolone Acetonide Otic Oil 0.01%,3208069,CDM,250,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NF-ReliOn Lancing Device,3208071,CDM,637,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NF-TrueMetrixControlSolution Level 3 Dev,3208072,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Vimpat Oral Tablet 100MG,3208073,CDM,637,RC,,,outpatient,,,78,58.5,,62.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.39,62.4,
NF-1-HEXANOL LIQUID,3208074,CDM,250,RC,,,outpatient,,,0.15,0.11,,0.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.06,0.12,
NF-Paxil Oral Tablet 30MG,3208076,CDM,250,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3208077,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-clonazePAM Tablet 1MG,3208078,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
HGB A2 QUANTITATION,2800349,CDM,301,RC,83021,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,81.6,
PREGNENOLONE,2800487,CDM,300,RC,84140,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.33,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.33,81.6,
SFMC MYCOPHENOLIC ACID SERUM,2800698,CDM,301,RC,80180,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,52.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,81.6,
NF-Diclofenac Sodium Topical Gel 3%,3208083,CDM,637,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Relion NovoLOG Inj Soln 100U/1ML,3208084,CDM,250,RC,,,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
NF-Systane Ophth Solution,3208085,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
FACTOR V ACTIVITY,2801068,CDM,302,RC,85230,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,81.6,
NF-Saphris Sublingual Tablet 10MG,3208089,CDM,250,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
NF-Levothyroxine Oral Tablet 200MCG,3208090,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Rexulti Oral Tablet 3MG,3208091,CDM,250,RC,,,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
NF-OLANZapine Oral Tablet 2.5MG,3208093,CDM,637,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-ZyPREXA Tablet 2.5MG,3208094,CDM,637,RC,,,outpatient,,,59,44.25,,47.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.74,47.2,
NF-Lotrel Oral Capsule 10MG-40MG,3208095,CDM,250,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Jardiance Oral Tablet 10MG,3208096,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Rexulti Oral Tablet 1MG,3208097,CDM,250,RC,,,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
NF-Depo-Testosterone IM Oil 200MG/1ML,3208098,CDM,637,RC,,,outpatient,,,93,69.75,,74.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.42,74.4,
NF-Sildenafil Citrate Tablet 100MG,3208099,CDM,250,RC,,,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
NF-valACYclovir HCl Oral Tablet 500MG,3208100,CDM,637,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
NF-Spironolactone Oral Tablet 100MG,3208101,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Mexiletine HCl Capsule 150MG,3208102,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Lortab 10/500 Oral Tablet 10MG-500MG,3208104,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Inderal LA Oral Cap ER 60MG,3208106,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Novaplus Tacrolimus Oral Capsule 0.5M,3208107,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-LaMICtal XR Extended Release Tab 100M,3208108,CDM,250,RC,,,outpatient,,,133,99.75,,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.52,106.4,
NF-Requip XL Oral Tab ER 2MG,3208109,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Requip XL Oral Tab ER 2MG,3208110,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Aggrenox Oral Cap ER 200MG-25MG,3208113,CDM,637,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
NF-Inderal LA Oral Cap ER 60MG,3208115,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3208116,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Rhopressa Ophthalmic Solution 0.02%,3208117,CDM,637,RC,,,outpatient,,,554,415.5,,443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,304.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.93,443.2,
NF-Drisdol Oral LiquidFilledCapsule 5000,3208118,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Rhopressa Ophthalmic Solution 0.02%,3208120,CDM,250,RC,,,outpatient,,,554,415.5,,443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,304.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.93,443.2,
NF-Rexulti Oral Tablet 1MG,3208121,CDM,250,RC,,,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
NF-Jardiance Oral Tablet 25MG,3208122,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Leflunomide Oral Tablet 20MG,3208123,CDM,250,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3208124,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
CLINIMIX 4.25/5% 1000 ML,3208126,CDM,636,RC,,,both,,,147.29,110.47,,117.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.27,147.29,
NF-acetaZOLAMIDE Tablet 250MG,3208127,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-Stiolto Respimat Inh 2.5-2.5MCG/1Act,3208129,CDM,250,RC,,,outpatient,,,521,390.75,,416.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,209.65,416.8,
NF-Trulance Oral Tablet 3MG,3208130,CDM,250,RC,,,outpatient,,,79,59.25,,63.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.79,63.2,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3208131,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Adderall XR Oral Cap ER 20MG,3208132,CDM,250,RC,,,outpatient,,,31,23.25,,24.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,24.8,
NF-Icar-C Tablet,3208133,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Linzess Oral Capsule 72MCG,3208134,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Proair HFA Inh Susp 0.09MG/1Act,3208135,CDM,637,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
NF-Trintellix Oral Tablet 10MG,3208136,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Creon Oral Cap DR 24000U-76000U-12000,3208137,CDM,250,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
NF-Vascepa Oral Liquid Filled Cap 1GM,3208138,CDM,250,RC,,,outpatient,,,13,9.75,,10.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.23,10.4,
NF-Auvelity Tab ER 45MG-105MG,3208140,CDM,250,RC,,,outpatient,,,77,57.75,,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.98,61.6,
NF-Benicar HCT Oral Tablet 40MG-12.5MG,3208142,CDM,250,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
"NF-dilTIAZem HCl Oral Capsule, ER 180MG",3208143,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Diflucan Tablet 200MG,3208146,CDM,637,RC,,,outpatient,,,277,207.75,,221.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,111.46,221.6,
NF-Insulin Glargine SubQ Soln 100U/1ML,3208147,CDM,637,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
NF-Vibramycin Hyclate Capsule 100MG,3208149,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Amitriptyline HCl Oral Tablet 150MG,3208150,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Zegerid Oral Capsule 40MG-1100MG,3208151,CDM,250,RC,,,outpatient,,,489,366.75,,391.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,244.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,268.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,366.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,391.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,196.77,391.2,
NF-Tiadylt Extended Release Capsule 360M,3208152,CDM,250,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-Budesonide Delayed Release Capsule 3M,3208153,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Linzess Oral Capsule 290MCG,3208154,CDM,250,RC,,,outpatient,,,76,57,,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.58,60.8,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3208155,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Breztri Aerosphere Inh Aer Liq,3208156,CDM,250,RC,,,outpatient,,,259,194.25,,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.22,207.2,
XOFLUZA 80 MG TABLET,3208157,CDM,250,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3208158,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Xofluza Oral Tablet 80MG,3208159,CDM,250,RC,,,outpatient,,,706,529.5,,564.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,388.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,284.09,564.8,
VORICONAZOLE 200 MG,3208160,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Unisom Tablet 25MG,3208161,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-hydrALAZINE HCl Tablet 100MG,3208163,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Bisoprolol Fumarate Tablet 5MG,3208166,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-hydrALAZINE HCl Tablet 100MG,3208168,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Bisoprolol Fumarate Tablet 5MG,3208169,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Carboxymethylcelull Sod Ophth Soln 0.,3208172,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Amantadine HCl Oral Capsule 100MG,3208173,CDM,250,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Omega-3-Acid Ethyl Esters Liq Cap 1GM,3208176,CDM,250,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
NF-Propranolol HCl Tablet 80MG,3208177,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-QUEtiapine Oral Tablet 400MG,3208178,CDM,250,RC,,,outpatient,,,73,54.75,,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.38,58.4,
NF-acetaZOLAMIDE Tablet 250MG,3208179,CDM,250,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
NF-aMILoride HCl Tablet 5MG,3208180,CDM,250,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-Oxtellar XR Oral Tab ER 600MG,3208181,CDM,250,RC,,,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.63,76.8,
NF-Rayaldee Oral Cap ER 30MCG,3208182,CDM,250,RC,,,outpatient,,,174,130.5,,139.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.02,139.2,
NF-BUPROPION HCL ORAL TAB ER 100MG,3208183,CDM,250,RC,,,outpatient,,,7.19,5.39,,5.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.89,5.75,
NF-FreeStyle Libre 2 Reader Device,3208184,CDM,637,RC,,,outpatient,,,310,232.5,,248,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.74,248,
NF-FreeStyle Libre 2 Sensor Device,3208185,CDM,637,RC,,,outpatient,,,271,203.25,,216.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,149.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,109.05,216.8,
NF-Gvoke HypoPen SubQ Soln 0.5MG/0.1ML,3208186,CDM,637,RC,,,outpatient,,,13623,10217.25,,10898.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5481.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6811.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6811.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6811.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6811.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7492.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10217.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10217.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10217.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10217.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5481.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5481.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10217.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5481.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,10898.4,
NF-Promethazine HCl Tablet 50MG,3208187,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Depakote Oral Tab DR 125MG,3208188,CDM,637,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NF-glipiZIDE-metFORMIN Tab 5MG-500MG,3208189,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Levocetirizine Dihydrochloride Tab 5M,3208190,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Movantik Oral Tablet 25MG,3208192,CDM,637,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
NF-Nuedexta Oral Capsule 20MG-10MG,3208194,CDM,637,RC,,,outpatient,,,112,84,,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.07,89.6,
NF-Trelegy Ellipta 100/62.5/25MCG/INH,3208195,CDM,637,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-AZO CRANBERRY ORAL LIQ CAP 250MG-60MG,3208196,CDM,250,RC,,,outpatient,,,0.76,0.57,,0.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.31,0.61,
NF-MOVANTIK ORAL TABLET 25MG,3208197,CDM,250,RC,,,outpatient,,,58.58,43.94,,46.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.57,46.86,
NF-Farxiga Oral Tablet 10MG,3208198,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Azithromycin Oral Tablet 250MG,3208199,CDM,637,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
NF-Trospium Chloride Oral Tablet 20MG,3208201,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-HydrOXYzine HCl Tablet 50MG,3208202,CDM,637,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
NF-amLODIPine-valsartan Tab 10MG-160MG,3208203,CDM,250,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
NF-HYDROmorphone HCl Oral Tablet 8MG,3208204,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Mounjaro SubQ Soln 5MG/0.5ML,3208205,CDM,250,RC,,,outpatient,,,2271,1703.25,,1816.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1135.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1249.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1703.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,913.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,913.85,1816.8,
NF-Trelegy Ellipta 200/62.5/25MCG/INH,3208206,CDM,250,RC,,,outpatient,,,47,35.25,,37.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.91,37.6,
NF-Oxtellar XR Oral Tab ER 600MG,3208207,CDM,250,RC,,,outpatient,,,96,72,,76.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.63,76.8,
NF-Rayaldee Oral Cap ER 30MCG,3208208,CDM,250,RC,,,outpatient,,,174,130.5,,139.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.02,139.2,
NF-Alendronate Sod Oral Tablet 35MG,3208209,CDM,250,RC,,,outpatient,,,71,53.25,,56.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.57,56.8,
NF-Aspirin/Butalbital/Caffeine/Code Caps,3208211,CDM,250,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
NF-LORAZEPAM INJ SOLN 2MG/1ML,3208213,CDM,250,RC,,,outpatient,,,41.06,30.8,,32.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.52,32.85,
NF-MORPHINE SULFATE ORAL SOLUTION 20MG/1,3208214,CDM,250,RC,,,outpatient,,,2.64,1.98,,2.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.06,2.11,
NF-Theophylline Tablet 300MG,3208215,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Budesonide Delayed Release Capsule 3M,3208216,CDM,250,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
NF-Droxia Capsule 400MG,3208219,CDM,250,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Biktarvy Oral Tab 50MG-200MG-25MG,3208220,CDM,250,RC,,,outpatient,,,561,420.75,,448.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,308.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,225.75,448.8,
NF-Droxia Capsule 400MG,3208221,CDM,637,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
NF-Amitriptyline Oral Tablet 100MG,3208222,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-diphenhydrAMINE Oral Capsule 25MG,3208223,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Zyloprim Oral Tablet 300MG,3208230,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
NF-Lotrel Oral Capsule 5MG-40MG,3208232,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NF-Farxiga Oral Tablet 10MG,3208233,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Omeprazole Oral Tablet DR 20MG,3208234,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Lunesta Tablet 3MG,3208237,CDM,250,RC,,,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,70.4,
NF-Blood GLucose Monitoring System,3208240,CDM,637,RC,,,outpatient,,,57,42.75,,45.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.94,45.6,
NF-Aeroeclipse Nebulizer,3208242,CDM,637,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
NF-Jardiance Oral Tablet 10MG,3208243,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-D3 5000 Oral Liq Cap 125MCG,3208245,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-Farxiga Oral Tablet 10MG,3208247,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-amLODIPine/Benazepril HCl Cap 10MG-40,3208248,CDM,637,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
NF-Levocetirizine Dihydrochloride Tab 5M,3208249,CDM,250,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NF-Farxiga Oral Tablet 10MG,3208250,CDM,250,RC,,,outpatient,,,46,34.5,,36.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.51,36.8,
NF-Trulicity SubQ Soln 1.5MG/0.5ML,3208251,CDM,250,RC,,,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,984,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,1574.4,
NF-Jardiance Oral Tablet 10MG,3208252,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Senokot S Oral Tablet 50MG-8.6MG,3208253,CDM,637,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
NF-LORazepam Intensol Concentrate 2MG/ML,3208254,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Morphine Sulfate Oral Solution 20MG/1,3208255,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-LORazepam Intensol Concentrate 2MG/ML,3208256,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Morphine Sulfate Oral Solution 20MG/1,3208257,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
NF-Mirtazapine Tablet 30MG,3208259,CDM,637,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NF-Tiadylt ER Oral Capsule ER 180MG,3208260,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NF-Jardiance Oral Tablet 10MG,3208261,CDM,250,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
NF-Xigduo XR Oral Tablet ER 5MG-1000MG,3208264,CDM,250,RC,,,outpatient,,,41,30.75,,32.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.5,32.8,
ADD-ON SET 11324,3300001,CDM,272,RC,,,outpatient,,,30.5,22.88,,24.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.27,24.4,
ANESTHESIA PRIMARY SET-CC1272,3300002,CDM,272,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
PT MIXING STUDY,2801084,CDM,300,RC,85611,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.3,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.97,81.6,
ARM BOARD LONG 10668,3300004,CDM,271,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
ARM BOARD MEDIUM 11524/10420,3300005,CDM,271,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
ARM BOARD SHORT 10290,3300006,CDM,271,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
CLAVE MACRO/EXT CC1320-473447,3300007,CDM,272,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
IL CANNULA,3300009,CDM,272,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
IL CONN LOOP 2N3372,3300010,CDM,272,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
IL THR/LK/CAN 303369,3300011,CDM,272,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
INFUSION SET LG20-100Y-10277,3300012,CDM,272,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
INFUSION SET-HUBER,3300013,CDM,272,RC,,,outpatient,,,22.5,16.88,,18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.05,18,
IV ADD ON FILTER-10757,3300019,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
IV BAG ACCESS SPIKE C5-15-10765,3300020,CDM,272,RC,,,outpatient,,,11.5,8.63,,9.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.63,9.2,
IV BLOOD PUMP V2560-10805,3300021,CDM,271,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
IV BLOOD SET CC3120-10062,3300022,CDM,272,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
IV CATH 22G X 1 10399,3300023,CDM,258,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
IV CATH 22G X 1 10587,3300024,CDM,258,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
IV CATH 24G X .56-10586,3300025,CDM,258,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
IV CATH 24G X .75-10378,3300026,CDM,258,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
IV CONNECTOR-10656,3300027,CDM,272,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
IV FILTER IVEX,3300028,CDM,272,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
IV INJ SET 2N3399-10581,3300029,CDM,272,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
IV J LOOP EXT SET-10057,3300030,CDM,272,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
IV MACROBORE EXTEN-SET,3300031,CDM,272,RC,,,outpatient,,,14,10.5,,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.63,11.2,
IV NITRO SET V7450-10691,3300032,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
IV PRIMARY MINI-DROP CC1280-10690,3300033,CDM,272,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
IV PRIMARY SET 352442-10130,3300034,CDM,272,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
IV PRIMARY VENTED SET CC3150-10759,3300035,CDM,272,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
IV PRIMARY W/FILTER VENT 375105-10465,3300036,CDM,272,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
IV SECONDARY SET VENTED V1922-10760,3300037,CDM,272,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
IV TRANSFER SET-513548-10466,3300038,CDM,272,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
IV TUBE VALVE SPIKE ASSEMBLY,3300039,CDM,258,RC,,,outpatient,,,14.7,11.03,,11.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.92,11.76,
IV VIAL ACCESS SPIKE C5-50-10657,3300040,CDM,272,RC,,,outpatient,,,11,8.25,,8.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.43,8.8,
NSS 1/2NS 1000ML,3300041,CDM,258,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
D5 .2 SOD CHLOR 500 ML,3300042,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
IV-D5 .33NS 1000ML,3300043,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
D5 1/2NS 1000ML INJ,3300044,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
D5 1/2NS 250ML,3300045,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
D5 1/2NS 500ML,3300046,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
D5 1/2NS-K10 1000ML,3300047,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
IV-D5 1/2NS-K30 1000ML-10906,3300048,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
D5 1/2NS-K40 1000ML,3300049,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
PTT MIXING STUDY,2801085,CDM,300,RC,85730,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3,81.6,
D5K30 1000ML,3300051,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
IV-D5K40 1000ML-10527,3300052,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
IV-D5K40 1000ML-10945,3300053,CDM,258,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
SFMC VON WILLEBRAND PANEL,2801277,CDM,300,RC,85247,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.47,81.6,
HOLTER EPATCH HOOKUP 3-7 DAYS,5500015,CDM,731,RC,93242,HCPCS,outpatient,,,102,76.5,,81.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,86.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,86.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.28,86.81,
IV-D5NS 250ML,3300056,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CPT ADD FOR DEX SUPP TEST,2801430,CDM,301,RC,80299,HCPCS,outpatient,,,102.5,76.88,,82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,82,
5 HIAA 24 HOUR URINE,2800019,CDM,301,RC,83497,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.45,82.4,
ANTI-THYROGLOBULIN AB,2800086,CDM,300,RC,86800,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.95,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.95,82.4,
D5W 100ML,3300060,CDM,258,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
IV-D5W 100ML-10125,3300061,CDM,258,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
D5W 250ML,3300062,CDM,258,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
CELIAC PANEL,2800149,CDM,300,RC,82784,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,82.4,
IV-D5W 50ML-10126,3300064,CDM,258,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
DEXTROSE 10% 1000ML,3300065,CDM,258,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
DEXTROSE 10% 500ML,3300066,CDM,258,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
IV-DEXTROSE 20%,3300067,CDM,258,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
ISOLYTE 500ML,3300068,CDM,258,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
IV-MANITOL 10%,3300069,CDM,258,RC,,,outpatient,,,43.5,32.63,,34.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.5,34.8,
IV-MANITOL 20%,3300070,CDM,258,RC,,,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,46.4,
IV-NSS 1/2 1000ML-10097,3300071,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
DRUG SCREEN-URINE FOR BATH SALTS,2800251,CDM,301,RC,80307,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
NSS 100ML,3300073,CDM,258,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
IV-NSS 150ML,3300074,CDM,258,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
DRUG SCREEN-URINE FOR SYNTHETIC THC,2800252,CDM,301,RC,80307,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
GROWTH HORMONE  SERUM,2800313,CDM,300,RC,83003,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.33,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.67,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.33,82.4,
IV-NSS 50ML-S8004-10061,3300077,CDM,258,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
IV-NSS 50ML-10061,3300078,CDM,258,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
HEPATITIS C ANTIBODY SCREEN WITH REFLEX,2800338,CDM,302,RC,86803,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.13,82.4,
MYOGLOBIN  URINE,2800443,CDM,301,RC,83874,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.46,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.46,82.4,
OHC STERIODS 17 OHC,2800459,CDM,301,RC,83491,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,61.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,61.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,82.4,
IV-SOD CHL 3%,3300082,CDM,258,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
IV-SOD CHL 45 500ML,3300083,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
IV-SOD CHL 5% HYPERTO,3300084,CDM,258,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
NSS  500CC IRRIGATION,3300085,CDM,258,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
PLATELET ANTIBODIES,2800480,CDM,302,RC,86022,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.18,82.4,
SMA SURVEY - VET PANELS,2800565,CDM,300,RC,80019,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
SECONDARY SET V1921-10058,3300088,CDM,272,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
TUBING  Y  BLOOD,3300089,CDM,272,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
GENERAL EYE PACK,3510030,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
ALCON IOL LENS,3510031,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
GC BY NAA,2800585,CDM,300,RC,87591,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
VMA RANDOM URINE,2800654,CDM,301,RC,84585,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.75,82.4,
5 HIAA RANDOM URINE,2800717,CDM,301,RC,82570,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.59,82.4,
HEPARIN INDUCED PLATELET ANTIBODIES,2800838,CDM,302,RC,86022,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.18,82.4,
SFMC HEPATITIS C SCREEN,2801158,CDM,302,RC,86803,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.83,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.13,82.4,
HOMOVANILLIC ACID 24 HOUR URINE,2801187,CDM,301,RC,83150,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.2,82.4,
SFMC CELIAC PANEL,2801236,CDM,300,RC,82784,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,12.09,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,82.4,
INJ CONTRAST VENOGRAPHY,4000008,CDM,360,RC,36005TC,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,2701.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2701.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2701.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,2701.97,2701.97,
SFMC 5 HIAA 24 HOUR URINE,2801261,CDM,301,RC,83497,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.45,82.4,
"GC/CHLAMYDIA, PHARYNGEAL SWAB",2801297,CDM,306,RC,87491,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
"THYROGLOBULIN AB & THYROGLOBULIN, LCMS",2801436,CDM,300,RC,86800,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.95,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.95,82.4,
XR CERVICAL SPINE MIN 4 VIEW,4000035,CDM,324,RC,72050TC,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
XR CYSTOGRAM MIN 3 VIEW,4000048,CDM,320,RC,74430TC,HCPCS,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
PR S.I JOINTS 3 OR MORE VIEWS BILATERAL,4010103,CDM,972,RC,72202BI26,HCPCS,outpatient,,,103,77.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,61.8,61.8,
NM PH DOBUTAMINE 25 OMG,4400032,CDM,636,RC,J1250,HCPCS,both,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,103,
PHY RECERT OF HH POC,6100247,CDM,969,RC,G0179,HCPCS,outpatient,,,103,77.25,,,,,,other,Not separately reimbursable for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,53.2,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.02,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,38.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,54.26,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.76,62.02,
HGB A2 QUANTITATIVE,2800350,CDM,300,RC,83021,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,83.2,
LH,2800407,CDM,301,RC,83002,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.26,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,83.2,
PSA SCREENING,2800508,CDM,301,RC,G0103,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.31,100,,,fee schedule,100% UHC fee schedule for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.65,83.2,
PSA SCREENING,2800510,CDM,300,RC,G0103,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.1,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.31,100,,,fee schedule,100% UHC fee schedule for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.65,83.2,
MM BIOPSY COMPRESSION CONTAINER,4000021,CDM,270,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
CLORAZEPATE SERUM,2800880,CDM,301,RC,80346,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.58,83.2,
ERYTHROPOIETIN SERUM,2800920,CDM,301,RC,82728,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.81,83.2,
SFMC LH,2801129,CDM,301,RC,83002,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.26,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.52,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,83.2,
ANTI MULLERIAN HORMONE,2801307,CDM,302,RC,82397,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,83.2,
PSA DIAGNOSTIC,2801333,CDM,301,RC,84153,HCPCS,outpatient,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.19,83.2,
MEROPENEM 500 MG PREMIXED,3207061,CDM,636,RC,J2184,HCPCS,both,,,104,78,,83.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.85,104,
TX-COLLECT BLOOD IMPLANT VENOUS DEVICE,1600001,CDM,761,RC,36540,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.25,84,
EBV VIRAL CAPSID ANTIBODIES IGM,2800256,CDM,305,RC,86665,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.07,84,
EBV ANTIBODIES TO EARLY ANTIGEN  IGG,2800257,CDM,305,RC,86663,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.56,84,
FSH,2800286,CDM,301,RC,83001,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.28,84,
VOLATILES BLOOD,2800656,CDM,301,RC,80320,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.45,84,
INSULIN-LIKE GROWTH FACTOR BP3,2800709,CDM,301,RC,83520,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,84,
TRICHOMONAS BY NAA,2800861,CDM,306,RC,87661,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,102.1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,102.1,
CYTOPATH CELL ENHANCE TECH,2800931,CDM,301,RC,88112,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,146.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.24,146.58,
FACTOR XII ACTIVITY,2801017,CDM,302,RC,85280,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,84,
VON WILLEBRAND ANTIGEN,2801069,CDM,305,RC,85246,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.47,84,
SELENIUM SERUM,2801080,CDM,301,RC,84255,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,90.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,90.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,90.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.76,90.14,
SFMC FSH,2801127,CDM,301,RC,83001,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.64,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.58,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.58,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.28,84,
SFMC EBV ANTIB/VIRAL CAPSID ANTIGEN IGM,2801174,CDM,305,RC,86665,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.07,84,
SFMC EBV ANTIBODY EVALUATION,2801263,CDM,305,RC,86663,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.56,84,
SFMC FACTOR XII ACTIVITY,2801279,CDM,302,RC,85280,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,84,
CYTOPATH CELL ENHANCE TECH,2900929,CDM,301,RC,88112,HCPCS,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,146.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,57.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.24,146.58,
SERUM ERYTHROPOETIN,2800553,CDM,301,RC,82668,HCPCS,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.39,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.79,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.79,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.39,84.8,
NOROVIRUS DETECTION REALTIME PCR,2800716,CDM,300,RC,87798,HCPCS,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
RICKETTSIA ANTIBODY EACH ANTIBODY,2800847,CDM,302,RC,8675791,HCPCS,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.65,84.8,
XR COPY OF DISK,4000047,CDM,320,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
RICKETTSIA ANTIBODY EACH ANTIBODY,2800848,CDM,302,RC,8675791,HCPCS,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.65,84.8,
RICKETTSIA ANTIBODY EACH ANTIBODY,2800849,CDM,302,RC,8675791,HCPCS,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.65,84.8,
RESPIRATORY PANEL COMPONENT,2801350,CDM,300,RC,87486,HCPCS,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
RESPIRATORY PANEL COMPONENT,2801351,CDM,300,RC,87581,HCPCS,outpatient,,,106,79.5,,84.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
RUBELLA IGM,2800546,CDM,302,RC,86762,HCPCS,outpatient,,,106.5,79.88,,85.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.58,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,85.2,
RUBELLA IGG,2800547,CDM,302,RC,86762,HCPCS,outpatient,,,106.5,79.88,,85.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.58,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,85.2,
SFMC RUBELLA IGG,2801160,CDM,302,RC,86762,HCPCS,outpatient,,,106.5,79.88,,85.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.58,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.71,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,85.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.19,85.2,
HALOPERIDOL DECANOATE IM 50MG/1ML,3203768,CDM,636,RC,J1631,HCPCS,both,,,106.56,79.92,,85.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.61,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.88,106.56,
TX-NURSE VISIT,1600012,CDM,761,RC,99211,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,134.33,
TX-SUTURE REMOVAL,1600013,CDM,761,RC,99211,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,134.33,
BLOOD CLOT FACTOR IX TEST,2800116,CDM,300,RC,85250,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.52,85.6,
CARCINO EMBRYONIC ANTIGEN,2800148,CDM,301,RC,82378,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.48,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.48,85.6,
CH50,2800151,CDM,302,RC,86162,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.16,85.6,
SFMC CARCINO EMBRYONIC ANTIGEN,2801159,CDM,301,RC,82378,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.48,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,58.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.48,85.6,
WORK HARDENING; EACH ADDITIONAL HOUR,5100544,CDM,420,RC,97546GP,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,85.6,
WORK HARDENING; EACH ADDITIONAL HOUR,5100545,CDM,430,RC,97546GO,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.06,85.6,
ULTRASOUND GUID FOR VASCULAR ACCESS,6200307,CDM,360,RC,76937,HCPCS,outpatient,,,107,80.25,,85.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1,85.6,
"INFLU VACC, HIGH DOSE",6900033,CDM,982,RC,90662,HCPCS,outpatient,,,107,80.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,117.44,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,73.4,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,102.76,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,64.2,117.44,
ZOSYN 4.5GM INJ,3200979,CDM,636,RC,J2543,HCPCS,both,,,107.5,80.63,,86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.26,107.5,
LACTOFERRIN STOOL,2800866,CDM,302,RC,83631,HCPCS,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.81,86.4,
PHYSICIAN REVIEW/INTERPRETATION,5500009,CDM,985,RC,93018,HCPCS,outpatient,,,108,81,,,,,,other,Not separately reimbursable for physician setting,11.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,11.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.63,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,13.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,18.93,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,11.18,64.8,
ULTRASONIC GUIDE FOR NEEDLE PLACEMENT,6200306,CDM,360,RC,76942,HCPCS,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,108.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,108.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,108.94,
HOME HEALTH PATIENT CERTIFICATION,6900225,CDM,982,RC,G0180,HCPCS,outpatient,,,108,81,,,,,,other,Not separately reimbursable for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,78.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,68.87,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,78.7,
SB DISCH/LEVEL II,7000020,CDM,524,RC,99316,HCPCS,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
MYOGLOBIN,2800442,CDM,301,RC,83874,HCPCS,outpatient,,,108.5,81.38,,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.46,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.68,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.46,86.8,
TROPONIN I HS QUANTITATIVE,2800617,CDM,301,RC,84484,HCPCS,outpatient,,,108.5,81.38,,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.68,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.23,86.8,
SFMC TROPONIN,2801370,CDM,301,RC,84484,HCPCS,outpatient,,,108.5,81.38,,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,34.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.68,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.23,86.8,
SFMC MYOGLOBIN,28012001,CDM,301,RC,83874,HCPCS,outpatient,,,108.5,81.38,,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.46,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.68,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.8,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.46,86.8,
HOMOVANILLIC ACID HVA RANDOM URINE,2800360,CDM,300,RC,83150,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.13,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.2,87.2,
HSV 2 IGG AB,2800365,CDM,302,RC,86696,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,87.2,
HSV II IGM,2800366,CDM,302,RC,86696,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,87.2,
SFMC MICROSPORIDIA STAIN STOOL,2800469,CDM,300,RC,87207,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.99,87.2,
T-CELL ACTIVATION PROFILE,2800593,CDM,301,RC,86586,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.86,87.2,
HBV DNA,2800972,CDM,302,RC,86696,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,87.2,
PHOSPHATIDYLETHANOL,2801002,CDM,300,RC,80321,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.45,87.2,
MM MAMMO PADS,4000083,CDM,271,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SFMC HSV 1/2 ANTIGEN DETECTION,2801189,CDM,302,RC,87273,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,87.2,
SFMC HSV 1/2 ANTIGEN DETECTION,2801190,CDM,302,RC,87274,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,87.2,
CERV SPINE AP & LAT,6100183,CDM,320,RC,72040,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.86,129.44,
CERV SPINE AP & LAT,6900137,CDM,320,RC,72040,HCPCS,outpatient,,,109,81.75,,87.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,59.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,43.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.86,129.44,
INFLAMMATORY BOWEL DISEASE PROFILE,2801011,CDM,300,RC,86256,HCPCS,outpatient,,,109.65,82.24,,87.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.31,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,87.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,87.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,87.72,
MM MAMMO-LOCALIZATION NEEDLE,4000089,CDM,272,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
SURG FLAT WARTS 1-14,400140,CDM,360,RC,17110,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.26,266.88,
ANTI DNA DOUBLE STRAND,2800071,CDM,302,RC,86225,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.87,88,
ARSENIC LEVEL,2800089,CDM,301,RC,82175,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.48,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.48,88,
DIPHTHERIA ANTITOXOID AB,2800244,CDM,300,RC,86317,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,52.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,88,
LEAD BLOOD (PEDIATRIC),2800402,CDM,301,RC,83655,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.05,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.05,88,
LEAD BLOOD (ADULT),2800403,CDM,301,RC,83655,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.05,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.05,88,
PROLACTIN,2800492,CDM,301,RC,84146,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.69,88,
SFMC PROLACTIN,2801128,CDM,301,RC,84146,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.69,88,
SFMC LEAD BLOOD (VENOUS),2801216,CDM,301,RC,83655,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.05,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.05,88,
SFMC ANTI DNA DOUBLE STRAND,2801298,CDM,302,RC,86225,HCPCS,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.87,88,
PRO FEE PHARM MANAG/REVIEW OF MEDICATION,6600017,CDM,960,RC,90862,HCPCS,outpatient,,,110,82.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,66,66,
CULTURE-AFB ID BY DNA,2800882,CDM,306,RC,87149,HCPCS,outpatient,,,110.28,82.71,,88.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,60.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.02,88.22,
ETHYL GLUCURONIDE  URINE,2801003,CDM,300,RC,80307,HCPCS,outpatient,,,111,83.25,,88.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,61.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
MANIPULATION OF CHEST WALL,5200107,CDM,410,RC,94668,HCPCS,outpatient,,,111,83.25,,88.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.67,171.6,
DTAP/IPV  (KINRIX),6900042,CDM,982,RC,90696,HCPCS,outpatient,,,111,83.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,66.6,66.6,
BB PER ANTIGEN GRP I,3000021,CDM,300,RC,86905,HCPCS,outpatient,,,112,84,,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,479.01,
CHROMOSOME ANALYSIS HIGH RESOLUTION,2800166,CDM,311,RC,88291,HCPCS,outpatient,,,112.5,84.38,,90,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,79.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,79.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,79.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.31,90,
THALLIUM,2800600,CDM,300,RC,83018,HCPCS,outpatient,,,112.5,84.38,,90,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.98,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,61.88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.56,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.98,90,
CHLAMYDIA/GC GEN PROBE,2800155,CDM,306,RC,87590,HCPCS,outpatient,,,113,84.75,,90.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,62.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.44,90.4,
GC/CHLAMYDIA PROBE,2800298,CDM,300,RC,87490,HCPCS,outpatient,,,113,84.75,,90.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,62.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.37,90.4,
GEN PROBE/GC SCREEN,2800299,CDM,306,RC,87590,HCPCS,outpatient,,,113,84.75,,90.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,62.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.44,90.4,
MS PROFILE CSF,2800436,CDM,300,RC,83916,HCPCS,outpatient,,,113,84.75,,90.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,62.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.61,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.69,90.4,
VARICELLA TITER IGM,2800635,CDM,300,RC,86787,HCPCS,outpatient,,,113,84.75,,90.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,62.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,90.4,
DESIPRAMINE,2800237,CDM,301,RC,80335,HCPCS,outpatient,,,113.5,85.13,,90.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,90.8,
RESPIRATORY SYNCYTIAL VIRUS,2800534,CDM,302,RC,87634,HCPCS,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,184.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,184.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,184.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.1,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,91.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,91.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,91.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,91.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,91.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,91.26,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,70.2,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,112.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.1,184.84,
RETICULIN AB  IGA,2800535,CDM,301,RC,86255,HCPCS,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,91.2,
CL-KINRIX VACCINE,6000333,CDM,636,RC,J3301,HCPCS,both,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,114,
KINRIX VACCINE,6100449,CDM,636,RC,J3301,HCPCS,both,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,114,
SFMC ANTIBODY HATTS REFLEX,2800073,CDM,305,RC,86780,HCPCS,outpatient,,,115,86.25,,92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.29,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,63.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,92,
SEROTONIN SERUM,2800859,CDM,306,RC,84260,HCPCS,outpatient,,,115,86.25,,92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,109.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,109.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,109.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,63.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,40.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,40.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,30.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.49,109.38,
SOLUBLE LIVER ANTIGEN IGG ANTIBODY,2800964,CDM,301,RC,83516,HCPCS,outpatient,,,115,86.25,,92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,63.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,92,
OBS DISCHARGE,6100318,CDM,982,RC,99217,HCPCS,outpatient,,,115,86.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,69,69,
AC VISIT LEVEL II,6100327,CDM,987,RC,99232,HCPCS,outpatient,,,115,86.25,,,,,,other,Not separately reimbursable for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,123.57,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,108.12,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,46.42,123.57,
DISCHARGE LEVEL I,6100332,CDM,987,RC,99238,HCPCS,outpatient,,,115,86.25,,,,,,other,Not separately reimbursable for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,125.18,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,109.54,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,45.85,125.18,
INT I/P CONSULT II,6100340,CDM,521,RC,99252,HCPCS,outpatient,,,115,86.25,,92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.28,92,
EST PT CONSULT III,6100346,CDM,521,RC,99263,HCPCS,outpatient,,,115,86.25,,92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,46.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.28,92,
IND PSYCHOTHERAPY 20-30MIN,6300090,CDM,972,RC,90832,HCPCS,outpatient,,,115,86.25,,,,,,other,Not separately reimbursable for physician setting,42.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,42.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,42.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,65.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,65.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,105.09,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,65.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.95,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,42.97,105.09,
OBS D/C NOT SAME DAY AS ADMIT,7000024,CDM,982,RC,99217,HCPCS,outpatient,,,115,86.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,69,69,
OBS INITIAL LEVEL 1,7000025,CDM,982,RC,99218,HCPCS,outpatient,,,115,86.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,69,69,
OBSERVATION SUBSEQUENT-15 MINS,7000027,CDM,982,RC,99224,HCPCS,outpatient,,,115,86.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,69,69,
VANCOMYCIN 1.75GM PM,3207934,CDM,636,RC,J3370,HCPCS,both,,,115.35,86.51,,92.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.42,115.35,
BLINK REFLEX,5600000,CDM,922,RC,95933,HCPCS,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
SCREW 3.5MM NON-LOCKING 55MM,890143,CDM,278,RC,C1713,HCPCS,both,,,116.6,87.45,,93.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.92,869.4,
CA 125,2800126,CDM,302,RC,86304,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
CA 15-3,2800127,CDM,302,RC,86300,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
CA 19-9,2800128,CDM,302,RC,86301,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
CANCER ANTIGEN 15-3,2800137,CDM,302,RC,86300,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
C-PEPTIDE SERUM,2800191,CDM,300,RC,84681,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
PROGESTERONE,2800491,CDM,301,RC,84144,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.43,93.6,
SFMC BORDETELLA PERTUSSIS PCR,2800982,CDM,306,RC,87798,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
B PERTUSSIS ASSOCIATED CHG,2800983,CDM,306,RC,87798,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
SFMC PROGESTERONE,2801138,CDM,301,RC,84144,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.43,93.6,
SFMC C-PEPTIDE SERUM,2801171,CDM,300,RC,84681,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
SFMC CA 125,2801176,CDM,302,RC,86304,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
SFMC CA 19-9,2801198,CDM,302,RC,86301,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
SFMC CPT 87176 CHG ONLY,2801381,CDM,311,RC,87176,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.94,93.6,
CA 15-3 NELHC,6100429,CDM,302,RC,86300,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,93.6,
HOME HEALTH PATIENT RECERTIFICATION,6200388,CDM,510,RC,G0179,HCPCS,outpatient,,,117,87.75,,93.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,47.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.08,93.6,
CA 15-3,6900168,CDM,982,RC,86300,HCPCS,outpatient,,,117,87.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.81,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.81,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,20.81,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,20.81,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,20.81,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,20.81,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.3,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,20.81,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,29.13,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,20.81,70.2,
ADM INFLUENZA VIRUS VACCINE,1400002,CDM,771,RC,G0008,HCPCS,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.54,94.4,
HYDRATION EA ADDTIONAL HOUR W MOD 59,1400223,CDM,260,RC,9636159,HCPCS,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.48,94.4,
ER-INTRAVENOUS INF HYDRATIN ADDL HR,1400234,CDM,450,RC,96361,HCPCS,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.54,94.4,
HYDRATION EA ADDITIONAL HOUR,1400238,CDM,260,RC,96361,HCPCS,outpatient,,,118,88.5,,94.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50.18,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.54,94.4,
PR US ABD LIMITED,4110001,CDM,972,RC,7670526,HCPCS,outpatient,,,118,88.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,70.8,70.8,
K-WIRE 3 X 285MM,890150,CDM,278,RC,C1769,HCPCS,both,,,118.2,88.65,,94.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.56,118.2,
THYROXINE BINDING GLOBULIN,2800604,CDM,305,RC,84442,HCPCS,outpatient,,,119,89.25,,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.39,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,65.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,89.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.39,95.2,
PROCAINAMIDE 1GM/2ML INJ,3200702,CDM,636,RC,J2690,HCPCS,both,,,119.5,89.63,,95.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.09,119.5,
VANCOCIN 1GM INJ,3200906,CDM,636,RC,J3370,HCPCS,both,,,119.5,89.63,,95.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.09,119.5,
ADMIN COVID VACCINE 1ST DOSE PURPLE CAP,1899002,CDM,771,RC,90480,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VACCINE 2ND DOSE PURPLE CAP,1899003,CDM,771,RC,90480,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VACCINE 3RD DOSE PURPLE CAP,1899004,CDM,771,RC,90480,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VACCINE BSTR 4TH+ PURPLE CAP,1899007,CDM,771,RC,90480,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VACCINE 1ST DOSE GRAY CAP,1899008,CDM,771,RC,0051A,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VACCINE 2ND DOSE GRAY CAP,1899009,CDM,771,RC,0052A,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VACCINE 3RD DOSE GRAY CAP,1899010,CDM,771,RC,0053A,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VACCINE BOOSTR 4TH+ GRAY CAP,1899011,CDM,771,RC,0054A,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ADMIN COVID VAXPFIZER BIVALENT- GRAY CAP,1899013,CDM,771,RC,0124A,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,96,
VITAMIN B1 WHOLE BLOOD,2800647,CDM,300,RC,84425,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,74.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,74.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.84,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.61,96,
Special stains group 1,2800945,CDM,301,RC,88312,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,128.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,88.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,88.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.24,128.59,
HUMAN ANTI GIARDIA ANTIBODY PROFILE,2800969,CDM,301,RC,86674,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.36,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.72,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.36,96,
HYDROCODONE AND METABOLITE,2800975,CDM,301,RC,80150,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,96,
CHRONIC IDIOPATHIC URTICARIA,2801116,CDM,302,RC,86343,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.23,96,
SFMC VITAMIN B1 WHOLE BLOOD,2801213,CDM,300,RC,84425,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,74.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,74.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.84,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.61,96,
SFMC MANUAL CHARGE,2801344,CDM,301,RC,87798,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
SFMC VARICELLA  ZOSTER PCR,2801360,CDM,306,RC,87252,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.03,96,
DEXAMETHASONE SUPPRESSION TEST,2801429,CDM,301,RC,82533,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.15,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,96,
BARD DURALOC  BR LOCALIZER NEEDLES (ALL),4000177,CDM,271,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
CORE BIOPSY INSTURMENT ALL SIZES,4000178,CDM,271,RC,,,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
COAXIAL BIOPSY NEEDLE ALL SIZES,4000179,CDM,271,RC,,,outpatient,,,55,41.25,,44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.13,44,
GRID LINES FOR CT GUIDENCE,4000180,CDM,271,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
CIPRO 400MG IV PREMIX,3200147,CDM,636,RC,J0744,HCPCS,both,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,120,
PR NM MECKELS LOCALIZATION,4410021,CDM,972,RC,7829026,HCPCS,outpatient,,,120,90,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,72,72,
NSG HOME DISCHARGE LEVEL 2,6100245,CDM,525,RC,99316,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
SB DISCHARGE LEVEL 2,6100361,CDM,524,RC,99316,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
EST PT HOME VISIT 2,6100364,CDM,522,RC,99347,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
NW PT HOME VISIT LEVEL 1,6100476,CDM,522,RC,99341,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
EST PT HOME VISIT LEVEL 2,6100481,CDM,522,RC,99347,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
ENDOCERVICAL CURETTAGE,6100501,CDM,521,RC,57505,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1039.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,974.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,1039.68,
OBS SUBSEQUENT LEVEL 1,6100523,CDM,982,RC,99224,HCPCS,outpatient,,,120,90,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,72,72,
XR SCOLIOSIS 2 VIEWS,6100550,CDM,320,RC,72082,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,86.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,86.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,174.35,
ADMIN COVID VACC PFIZER BIVALENT BOOSTER,6100740,CDM,771,RC,0124A,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,38.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.81,96,
EST LEVEL 3 OV,6300072,CDM,510,RC,99213,HCPCS,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38,154.55,
PSYCHOTHERAPY FOR CRISIS; EACH ADDITIONA,6300197,CDM,972,RC,90840,HCPCS,outpatient,,,120,90,,,,,,other,Not separately reimbursable for physician setting,57.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,57.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,57.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,61.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,61.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,57.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.1,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,61.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,86.72,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,57.26,99.1,
PRO FEE IND/THERAPY 20-30 MIN,6600014,CDM,960,RC,90804,HCPCS,outpatient,,,120,90,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,72,72,
MEDICARE PAP SMEAR,6900254,CDM,982,RC,Q0091,HCPCS,outpatient,,,120,90,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,17.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,17.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,17.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,17.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,17.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,17.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.42,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,17.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,24.86,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,17.76,72,
SFMC PLATELET FUNCTION TEST,2800481,CDM,305,RC,85576,HCPCS,outpatient,,,121,90.75,,96.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,75.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,66.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,32.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.91,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.91,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.85,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.36,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.45,96.8,
BLASTOMYCES ABS,2800114,CDM,302,RC,86612,HCPCS,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.45,97.6,
CYCLIC AMP(URINE),2800227,CDM,301,RC,82030,HCPCS,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.9,97.6,
LEVETIRACETAM LEVEL,2800406,CDM,301,RC,80177,HCPCS,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,97.6,
SEX HORMONE BINDING GLOBULIN,2800556,CDM,300,RC,84270,HCPCS,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,76.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,97.6,
MRI SMART SET,4000203,CDM,270,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
SFMC LEVETIRACETAM LEVEL,2801132,CDM,301,RC,80177,HCPCS,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,97.6,
SFMC SEX HORMONE BINDING GLOBULIN,2801275,CDM,300,RC,84270,HCPCS,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,76.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,97.6,
MM Diag Dig Breast Tomosynt BIL 3D,4001160,CDM,401,RC,77062,HCPCS,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.87,187.02,
COMPATIBILITY AHG,2800178,CDM,300,RC,86922,HCPCS,outpatient,,,122.91,92.18,,98.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,232.4,
BB CROSSMATCH,2800180,CDM,300,RC,86920,HCPCS,outpatient,,,122.91,92.18,,98.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.09,232.4,
BB COMPATIBILITY TEST - INCUBATION,3000014,CDM,300,RC,86921,HCPCS,outpatient,,,122.91,92.18,,98.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.79,232.4,
BB CROSSMATCH,3000029,CDM,300,RC,86920,HCPCS,outpatient,,,122.91,92.18,,98.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,33.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.09,232.4,
CATH AND INTRO OF SALINE FOR HYSTEROSALP,4000211,CDM,320,RC,58340,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,135.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,135.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,135.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,135.03,135.03,
BB REFERENCE CROSSMATCH ADDED CHARGES,3000043,CDM,300,RC,86922,HCPCS,outpatient,,,122.91,92.18,,98.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,49.15,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.69,232.4,
MURINE TYPHUS ANTIBODIES  IGG,2800439,CDM,302,RC,86757,HCPCS,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,67.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,98.4,
SINEQUAN (DOXEPIN),2800561,CDM,301,RC,80335,HCPCS,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,98.4,
SOLU MEDROL 1000MG,3200798,CDM,636,RC,J2930,HCPCS,both,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.5,123,
EMG CRANIAL UNILAT,5600015,CDM,922,RC,95867,HCPCS,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.5,413.89,
"POSITIVE AIRWAY PRESSURE, CPAP INT MGMT",6200234,CDM,360,RC,94660,HCPCS,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.5,283.02,
BETA 2 MICROGLOBULIN,2800110,CDM,301,RC,82232,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.09,99.2,
CA 27-29,2800129,CDM,302,RC,86300,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,99.2,
CLOZARIL LEVEL,2800170,CDM,301,RC,80154,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.9,99.2,
ORGANIC ACID URINE TOTAL QUANTITATIVE,2800460,CDM,301,RC,83918,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,30.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.8,99.2,
RENIN,2800533,CDM,301,RC,84244,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.99,99.2,
BACTERIAL VAGINOSIS AND VAGINAL YEAST,2801186,CDM,306,RC,87102,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.45,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.2,99.2,
SFMC RENIN,2801221,CDM,301,RC,84244,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.18,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.99,99.2,
SFMC BETA 2 MICROGLOBULIN,2801269,CDM,301,RC,82232,HCPCS,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.09,99.2,
INFLUENZA A&B AB QUANTITATIVE,2800382,CDM,302,RC,86710,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,100,
MANGANESE BLOOD,2800419,CDM,300,RC,83785,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,75.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,34.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.65,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.32,100,
INFLUENZA A&B AB QUANTITATIVE,2800858,CDM,302,RC,86710,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.77,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.77,100,
STREPTOMYCIN SERUM,2800881,CDM,301,RC,82491,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
NOVEL CORONAVIRUS NAA,2801382,CDM,306,RC,U0003,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,62.5,100,
RMC COVID PCR,2801439,CDM,302,RC,87635,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,66.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.7,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.31,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,82.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.65,100,
FRAGILE X REFLEX CHARGE ONLY,2801445,CDM,311,RC,81243,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.26,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.52,121.66,
ROBAXIN 100 mg/mL 10mL (1000mg) INJ,3200751,CDM,636,RC,J2800,HCPCS,both,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,125,
DTAP (DAPTACEL VACC. LESS THAN 7 YR OLD),3206674,CDM,636,RC,90700,HCPCS,both,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,125,
PR XR COLON/SOLID COLUMN,4010045,CDM,972,RC,7427026,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMOGRAM UNILATERAL RT DIGITAL,4010087,CDM,972,RC,G020626RT,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMOGRAM UNILATERAL LT DIGITAL,4010088,CDM,972,RC,G020626LT,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMOGRAM DIGITAL SCREENING,4010169,CDM,972,RC,G020226,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR XR FLUORO FOR SPINE INJECTION,4010191,CDM,972,RC,7700326,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
DO NOT USE,4010194,CDM,972,RC,7432726,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR XR UPPER GI SERIES,4010196,CDM,972,RC,7424026,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMO SCREENING UNILATERAL LEFT*,4010202,CDM,972,RC,7706726,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMO SCREENING UNILATERAL RIGHT*,4010203,CDM,972,RC,7706726,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMO DIAGNOSTIC UNILATERAL LEFT*,4010207,CDM,972,RC,7706526LT,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMOGRAM DIAGNOSTIC BILAT*,4010208,CDM,972,RC,7706626,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMOGRAM SCREENING BILATERAL*,4010210,CDM,972,RC,7706726,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR MM MAMMO DIAGNOSTIC UNILATERAL RT *,4011147,CDM,972,RC,7706526RT,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR US VENOUS DOPPLER COMPLETE BILAT,4110034,CDM,972,RC,9397026,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR US VENOUS DOPPLER-UNILAT - RIGHT,4110035,CDM,972,RC,9397126RT,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR US BREAST UNILATERAL - LEFT LIMITED,4110045,CDM,972,RC,7664226LT,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR US ARTERIAL DOPPLER UPPER EXT - BILAT,4110047,CDM,972,RC,9393026,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
CT CT LD CHEST WO SCREEN,4300074,CDM,352,RC,71271,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,141.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,141.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,141.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,650,
PR NM LOCALIZATION-LIMITED (BREAST),4410017,CDM,972,RC,7880026,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR NM LUNG PERFUSION MULPITLE PROJECTION,4410019,CDM,972,RC,7858026,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR NM MUGA FIRST PASS,4410023,CDM,972,RC,7849626,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR NM TAGGED RED CELL,4410058,CDM,972,RC,7827826,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR NM TESTICULAR/FLOW,4410059,CDM,972,RC,7876126,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PR NM THYROID I 123 UPTAKE SIN OR MULTIP,4410061,CDM,972,RC,7801226,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
PULSE OX CHECK,5200070,CDM,460,RC,94760,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,100,
EXC BENIGN LESION <0.5CM,6000125,CDM,521,RC,11420,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,2216.25,
REPAIR SCALP  ARM  OR LEG EA ADD 5 CM,6000146,CDM,521,RC,13122,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
NEW PT LEVEL 2 OV,6000253,CDM,521,RC,99202,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,134.33,
PNEUMOCOCCAL,6000340,CDM,636,RC,90669,HCPCS,both,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,125,
EXC BENIGN LESION <0.5CM,6100063,CDM,521,RC,11420,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,2216.25,
REPAIR SCALP  ARM  OR LEG EA ADD 5 CM,6100076,CDM,521,RC,13122,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
BIOPSY OF VULVA   ONE LESION,6100113,CDM,521,RC,56605,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1039.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,974.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,1039.68,
X-RAY CERV SPIN AP 5 VIEWS,6100184,CDM,320,RC,72050,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,174.35,
NSG HOME ADMIT I,6100238,CDM,522,RC,99324,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
NH SUBSEQUENT STAY LEVEL 2,6100241,CDM,525,RC,99308,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
NSG HOME VISIT II,6100242,CDM,522,RC,99335,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
PNEUMOCOCCAL,6100268,CDM,636,RC,90669,HCPCS,both,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,125,
OBS ADMIT,6100319,CDM,982,RC,99218,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
AC ADM LEVEL I,6100322,CDM,987,RC,99221,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,130.4,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,114.1,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.52,130.4,
AC VISIT LEVEL III,6100328,CDM,987,RC,99233,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,185.94,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,162.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,66.52,185.94,
CONSULT OV LEVEL II,6100335,CDM,521,RC,99242,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
SB ADMIT LEVEL 1,6100354,CDM,524,RC,99304,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
SB DISCHARGE LEVEL 1,6100360,CDM,524,RC,99315,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
NURSING HOME VISIT,6100363,CDM,522,RC,99334,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
NEW PT LEVEL 2 OV,6100386,CDM,521,RC,99202,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,134.33,
NH ADMIT LEVEL 1,6100492,CDM,525,RC,99304,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
OFFICE OR OTHER O/P CONSULT-LEVEL 1,6200027,CDM,510,RC,99201,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
INJECTION FOR CHOLANGIOGRAPHY EXIST CATH,6200192,CDM,360,RC,47505,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
UNLISTED GASTROENTEROLOGY PROCEDURE,6200310,CDM,360,RC,91299,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,269.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,269.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,269.88,
UNLISTED PROCEDURE RECTUM,6200313,CDM,360,RC,45999,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,1228.22,
OFFICE OR OTHER OP CONSULT-BRIEF,6200401,CDM,360,RC,99241,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
REPAIR SCALP ARM OR LEG EA ADD 5 CM,6300123,CDM,972,RC,13122,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,72.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,80.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,80.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,80.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,80.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,72.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,80.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,80.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,129.23,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,80.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,113.08,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,72.74,129.23,
NEW LEVEL II OV,6300182,CDM,510,RC,99202,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,134.33,
SUBSEQUENT HOSPITAL LEVEL 2,7000004,CDM,987,RC,99232,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,123.57,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,77.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,108.12,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,46.42,123.57,
SB ADMIT LEVEL I,7000016,CDM,524,RC,99304,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
SB VISIT LEVEL II,7000022,CDM,524,RC,99308,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
PR US ARTERIAL DOPPLER UPPER EXT - BILA,41100047,CDM,972,RC,9393026,HCPCS,outpatient,,,125,93.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,75,75,
ISOVUE 370 100ML,90000823,CDM,255,RC,Q9967,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
CATHETER GUIDING X3,90005465,CDM,270,RC,C1887,HCPCS,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
FLEX SIG W BX,4010077,CDM,490,RC,,,outpatient,,,1400,1050,,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,770,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.36,1120,
KIDMED ENCOUNTER,6100010,CDM,521,RC,T1015,HCPCS,outpatient,,,125.38,94.04,,100.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.45,100.3,
COMPLEMENT 3 TOTAL,2800181,CDM,301,RC,86160,HCPCS,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,100.8,
IMMUNOELECTROPHORESIS SERUM,2800373,CDM,302,RC,86320,HCPCS,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,79.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,79.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,79.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.9,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.96,100.8,
IMMUNOELECTROPHORESIS URINE,2800374,CDM,302,RC,86325,HCPCS,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,78.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% UHC fee schedule for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.56,100.8,
SFMC COMPLEMENT 3 TOTAL,2801223,CDM,301,RC,86160,HCPCS,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,100.8,
SFMC IMMUNOELECTROPHORESIS URINE,2801287,CDM,302,RC,86325,HCPCS,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,78.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,78.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.56,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% UHC fee schedule for outpatient setting,23.13,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.56,100.8,
NM PH TC99M MEBROFENIN PER 15 MIC,4400039,CDM,343,RC,A9537,HCPCS,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,100.8,
MECHANICAL CHEST WALL MANIPULATION,5200110,CDM,410,RC,94669,HCPCS,outpatient,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,100.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,100.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,283.02,
CL-TDAP,6000228,CDM,636,RC,90715,HCPCS,both,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,126,
"HEP B 3 DOSE SCHED, AGES 20 >",6000237,CDM,636,RC,90746,HCPCS,both,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,126,
TDAP,6100281,CDM,636,RC,90715,HCPCS,both,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,126,
HEP B AGES 20,6100293,CDM,636,RC,90746,HCPCS,both,,,126,94.5,,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.7,126,
SUBSEQUENT HOSPITAL CARE-PER DAY-LEVEL1,6200041,CDM,963,RC,99231,HCPCS,outpatient,,,126,94.5,,,,,,other,Not separately reimbursable for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,77.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,48.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,68.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,25.81,77.98,
INSULIN ANTIBODY SCREEN,2800384,CDM,302,RC,86337,HCPCS,outpatient,,,127,95.25,,101.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.7,101.6,
PROTEIN C RESISTANCE,2800495,CDM,305,RC,85307,HCPCS,outpatient,,,127,95.25,,101.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.66,101.6,
CULTURE-ANAEROBIC IDENT 1,2801070,CDM,306,RC,87076,HCPCS,outpatient,,,127,95.25,,101.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,69.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.04,101.6,
HEMOSTATIC VAGINAL PACKING,6100467,CDM,521,RC,57180,HCPCS,outpatient,,,127,95.25,,101.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,51.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.1,451.36,
ZITHROMAX 500MG IV,3200963,CDM,636,RC,J0456,HCPCS,both,,,127.25,95.44,,101.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.21,127.25,
HEMOSIDERIN URINE,2800332,CDM,300,RC,83070,HCPCS,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,70.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.37,102.4,
LEVSIN 0.5MG/ML INJ,3200467,CDM,636,RC,J1980,HCPCS,both,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,128,
XR C ARM UP TO ONE HOUR,4000030,CDM,320,RC,76000TC,HCPCS,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
XR LUMBAR SPINE 2 OR 3 VIEW,4000080,CDM,320,RC,72100TC,HCPCS,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
ER VISIT LEVEL III,6100349,CDM,521,RC,99283,HCPCS,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,362.12,
SENTINEL NODE IDENTIFICATION,6200285,CDM,360,RC,38792,HCPCS,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,356.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,356.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,356.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,359.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,359.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,359.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,538.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,574.44,
SFMC EBV DNA QUANT,2800123,CDM,300,RC,87799,HCPCS,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,70.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.55,151.24,
CMV PCR STOOL,2801309,CDM,300,RC,87497,HCPCS,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,70.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.42,151.24,
EXC BENIGN LESION 0.6CM TO 1.0CM,600126,CDM,521,RC,11421,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,1316.03,
ROUTINE PAP,610091,CDM,521,RC,Q0091,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.52,104,
SFMC HEAVY METALS PROFILE,2800326,CDM,300,RC,82300,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,81.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.82,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,30.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,23.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.82,104,
PR XR COLON/SOLID COLUMN,4010187,CDM,972,RC,7427026,HCPCS,outpatient,,,130,97.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,78,78,
EXCISION BENIGN LESION < 0.5CM,6000120,CDM,521,RC,11400,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,959.13,
EXC BENIGN LESION 0.6CM TO 1.0CM,6000126,CDM,521,RC,11421,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,1316.03,
EST LEVEL 3 OV W/MODIFIER -25,6000261,CDM,521,RC,9921325,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
RURAL HEALTH VISIT,6000262,CDM,521,RC,99213,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,154.55,
PER COMP (AGE UNDER 1),6000272,CDM,521,RC,99391,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
PER COMP (AGE 01-4),6000273,CDM,521,RC,99392,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
PER COMP (AGE 05-11),6000274,CDM,521,RC,99393,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
PER COMP (AGE 12-17),6000275,CDM,521,RC,99394,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
PHYSICAL EXAM (EMPLOYMENT/SPORTS),6000280,CDM,521,RC,99499,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
WELCOME TO MCARE EXAM,6000285,CDM,521,RC,G0438,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,195,
TELEHEALTH AUDIO ONLY,6000359,CDM,521,RC,G2025,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,139.56,
XR ACUTE ABD SERIES +1VIEW CHEST,6100217,CDM,320,RC,74022TC,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
OBS SUBSEQUENT LEVEL 2,6100325,CDM,982,RC,99225,HCPCS,outpatient,,,130,97.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,78,78,
PER COMP (AGE 12-17),6100376,CDM,521,RC,99394,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
RURAL HEALTH VISIT,6100392,CDM,521,RC,99213,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,154.55,
REMOVAL FB THIGH OR KNEE,4010127,CDM,360,RC,,,outpatient,,,2051,1538.25,,1640.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1128.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1538.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,825.32,1640.8,
EXC BENIGN LESION 0.6CM TO 1.0CM,6100470,CDM,521,RC,11421,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,1316.03,
PHYSICAL EXAM (EMPLOYMENT/SPORTS),6100485,CDM,521,RC,99499,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
EXCISION BENIGN LESION < 0.5CM,6100488,CDM,521,RC,11400,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,959.13,
WELCOME TO MCARE EXAM,6100506,CDM,521,RC,G0438,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,130,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,195,
TELEHEALTH AUDIO ONLY,6100722,CDM,521,RC,G2025,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,93.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,139.56,
SUBSEQUENT OBSERVATION CARE,6200480,CDM,360,RC,99224,HCPCS,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
INT COMP (AGE UNDER 1),6900082,CDM,982,RC,99381,HCPCS,outpatient,,,130,97.5,,,,,,other,Not separately reimbursable for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.07,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,64.85,115.07,
EST LVL III TELEMED,6900214,CDM,982,RC,99213,HCPCS,outpatient,,,130,97.5,,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.8,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,89.95,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,41.53,102.8,
OBSERVATION SUBSEQUENT 25 MINS,7000026,CDM,982,RC,99225,HCPCS,outpatient,,,130,97.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,78,78,
CLONAZEPAM,2800168,CDM,301,RC,80150,HCPCS,outpatient,,,131,98.25,,104.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,72.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,104.8,
DIPHENHYDRAMINE,2800995,CDM,301,RC,80374,HCPCS,outpatient,,,131,98.25,,104.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.84,104.8,
IV PUSH-SAME DRUG,1600014,CDM,260,RC,9637659,HCPCS,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
IV PUSH-INITIAL WITH MOD 59,1600015,CDM,260,RC,9637659,HCPCS,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
LYME TITERS,2800416,CDM,302,RC,86618,HCPCS,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.51,105.6,
TRICYCLIC ANTIDEPRESSANTS SCREEN SERUM,2800614,CDM,300,RC,G0431,HCPCS,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
SFMC LYMES TITER,2801217,CDM,302,RC,86618,HCPCS,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.51,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.03,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.51,105.6,
DISCHARGE LEVEL II,6100333,CDM,987,RC,99239,HCPCS,outpatient,,,132,99,,,,,,other,Not separately reimbursable for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,79.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,177.94,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,66.67,177.94,
ANOSCOPY,6200450,CDM,360,RC,46600,HCPCS,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,171.6,
DEPO-PROVERA 150MG INJ,3200228,CDM,636,RC,J1050,HCPCS,both,,,132.5,99.38,,106,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.32,132.5,
HOLTER EPATCH HOOKUP 8-14 DAYS,5500017,CDM,731,RC,93246,HCPCS,outpatient,,,133,99.75,,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,142.76,
PHY CERT OF HH POC,6100246,CDM,969,RC,G0180,HCPCS,outpatient,,,133,99.75,,,,,,other,Not separately reimbursable for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,79.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,63.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,78.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,49.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,68.87,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.19,79.8,
LOVENOX 40MG INJ,3200514,CDM,636,RC,J1650,HCPCS,both,,,133.5,100.13,,106.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.72,133.5,
METHYLMALONIC ACID QUANTITATIVE,2800425,CDM,301,RC,83921,HCPCS,outpatient,,,134,100.5,,107.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,73.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.21,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.81,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.6,107.2,
TOPAMAX,2800608,CDM,301,RC,80201,HCPCS,outpatient,,,134,100.5,,107.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,73.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.96,107.2,
SFMC TOPAMAX,2801293,CDM,301,RC,80201,HCPCS,outpatient,,,134,100.5,,107.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,73.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.92,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.96,107.2,
SFMC FLYSO CPT 85549 CHARGE ONLY,2801378,CDM,301,RC,85549,HCPCS,outpatient,,,134,100.5,,107.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,66.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,73.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.37,107.2,
PR NM BONE LIMITED AREA,4410005,CDM,972,RC,7830026,HCPCS,outpatient,,,134,100.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,80.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,80.4,80.4,
HEP B AGES 20,6900059,CDM,982,RC,90746,HCPCS,outpatient,,,134,100.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,80.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,112.61,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,98.53,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,112.61,
SOLUBLE TRANSFERRIN RECEPTOR,2801093,CDM,301,RC,84238,HCPCS,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,129.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.28,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,74.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,47.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,47.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,47.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,47.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,47.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,47.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.57,100,,,fee schedule,100% UHC fee schedule for outpatient setting,36.57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,36.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.28,129.11,
SFMC MAYO AEROBIC IDENTIFICATION,2801354,CDM,306,RC,87077,HCPCS,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,74.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.04,108,
STRAPPING ANKLE AND/OR FOOT,6100089,CDM,521,RC,29540,HCPCS,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.32,215.42,
SB SUBSEQUENT LEVEL 3,6100497,CDM,524,RC,99309,HCPCS,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.32,108,
NH SUBSEQUENT LEVEL 3,6100498,CDM,525,RC,99309,HCPCS,outpatient,,,135,101.25,,108,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,54.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.32,108,
FAMILY PSYCH W/O PATIENT,6300078,CDM,972,RC,90846,HCPCS,outpatient,,,135,101.25,,,,,,other,Not separately reimbursable for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,150.61,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,131.78,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60.76,150.61,
CABLE 5833L SURGICAL DISP SM CLIP 12 FT,5890114,CDM,275,RC,C1722,HCPCS,outpatient,,,135.2,101.4,,108.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.4,108.16,
CABLE 5833SL SURGICAL DISP SM CLIP 12FT,90008349,CDM,278,RC,33213,HCPCS,both,,,135.2,101.4,,108.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,108.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.4,15265.35,
EXTRIOL (E3),2800271,CDM,300,RC,82677,HCPCS,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,85.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.43,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.09,108.8,
INT I/P CONSULT III,6100341,CDM,521,RC,99253,HCPCS,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
FLUROGUIDE FOR VEIN DEV PROF CHARGE ONLY,6200172,CDM,360,RC,77001,HCPCS,outpatient,,,137,102.75,,109.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1,109.6,
STRAPPING SHOULDER,2800579,CDM,430,RC,29240,HCPCS,outpatient,,,138,103.5,,110.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55.53,171.6,
NASO/ORO-GASTRIC TUBE PLMT UNDERFLUROSC,6200213,CDM,360,RC,43752,HCPCS,outpatient,,,138,103.5,,110.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,252,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,252,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,252,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,75.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,103.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55.53,558.02,
URINE PORPHYRINS QUANTITATIVE,2800630,CDM,301,RC,84120,HCPCS,outpatient,,,138.5,103.88,,110.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,51.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.35,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,76.18,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.06,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.35,110.8,
TX-IV THERAPY UP TO 1 HR,1600011,CDM,260,RC,90760,HCPCS,outpatient,,,139,104.25,,111.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,55.93,111.2,
ALUMINUM  SERUM OR PLASMA,2800054,CDM,300,RC,82108,HCPCS,outpatient,,,139,104.25,,111.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.74,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,76.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.48,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.22,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.53,111.2,
NORTRIPTYLINE,2800449,CDM,301,RC,80335,HCPCS,outpatient,,,139,104.25,,111.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,111.2,
HEPATITIS B (AGES 11-19),6900057,CDM,982,RC,90743,HCPCS,outpatient,,,139,104.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,118.16,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,73.85,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,103.39,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.85,118.16,
DEPO-TESTOSTERONE  200MG/1ML,3200841,CDM,636,RC,J1071,HCPCS,both,,,139.37,104.53,,111.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.08,139.37,
DEPO-TESTOSTERONE  200MG/1ML 10 ml,3202577,CDM,636,RC,J1071,HCPCS,both,,,139.37,104.53,,111.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.08,139.37,
DEPO-TESTOSTERONE  200MG/1ML,6100841,CDM,636,RC,J1071,HCPCS,both,,,139.37,104.53,,111.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.08,139.37,
COMPRESSION SCREW 32MM,890043,CDM,278,RC,C1713,HCPCS,both,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,869.4,
DENIS-BROWNE SPLINT STRAPPING,2800235,CDM,430,RC,29590,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
ESTRONE (E1),2800267,CDM,300,RC,82679,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,88.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,32.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.47,112,
FINGER SPLINT APPLICATION-STATIC,2800281,CDM,430,RC,29130GO,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,178.23,
STRAPPING ANKLE OR FOOT,2800573,CDM,430,RC,29540,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,215.42,
STRAPPING ELBOW OR WRIST,2800574,CDM,430,RC,29260,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,112,
STRAPPING HAND OR FINGER,2800575,CDM,430,RC,29280,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,112,
STRAPPING HIP,2800576,CDM,430,RC,29520,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,171.6,
STRAPPING KNEE,2800577,CDM,430,RC,29530,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,171.6,
STRAPPING LOWER BACK,2800578,CDM,430,RC,29220,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
STRAPPING TOES,2800580,CDM,430,RC,29550,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,112,
STRAPPING UNNA BOOT,2800581,CDM,430,RC,29580,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,379.9,
SFMC ADENOSINE DEAMINASE,2801056,CDM,301,RC,82657,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.08,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.08,112,
SFMC CHOLESTEROL BODY FLUID,2801057,CDM,301,RC,84311,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.05,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.53,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.05,112,
PORPHOBILINOGEN DEAMINASE,2801316,CDM,301,RC,82657,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.08,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.08,112,
US SURGICAL SPECIMEN,4100065,CDM,402,RC,76098,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,433.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,433.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,743.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,697.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,772.62,
NM PH ADENOSINE PER 6 MG PER ML,4400028,CDM,636,RC,J0150,HCPCS,both,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,140,
OT RE EVAL  ATHL TRAINING EST POC,5197172,CDM,951,RC,97172GO,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
NT SUCTIONING; NASOTRACHEAL,5200075,CDM,410,RC,31720,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,152.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,152.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,283.02,
EXCISION BENIGN LESION <= 0.5CM,6000127,CDM,521,RC,11440,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,959.13,
REPAIR OF LACERATION TO FACE 2.6CM-5.0CM,6000140,CDM,521,RC,12013,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,375.41,
DTAP/HBV/POLIO,6000230,CDM,636,RC,90723,HCPCS,both,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,140,
NEW PT LEVEL 3 OV,6000254,CDM,521,RC,99203,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,154.55,
INT COMP (AGE 12-17),6000268,CDM,521,RC,99384,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
DTAP/HBV/POLIO,6100285,CDM,636,RC,90723,HCPCS,both,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,140,
INT COMP (AGE 12-17),6100369,CDM,521,RC,99384,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
NEW PT LEVEL 3 OV,6100387,CDM,521,RC,99203,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,154.55,
SB SUBSEQUENT LEVEL 1,6100495,CDM,524,RC,99307,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
EXCISION BENIGN LESION <= 0.5CM,6100508,CDM,521,RC,11440,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,959.13,
OBS SUBSEQUENT LEVEL 3,6100522,CDM,982,RC,99226,HCPCS,outpatient,,,140,105,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,84,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,84,84,
REPAIR OF LACERATION TO FACE 2.6CM-5.0CM,6100534,CDM,521,RC,12013,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,375.41,
GROUP THERAPY,6600004,CDM,915,RC,90853,HCPCS,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,205.08,
PRO FEE GROUP THERAPY,6600013,CDM,960,RC,90853,HCPCS,outpatient,,,140,105,,,,,,other,Not separately reimbursable for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,84,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,37.02,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,23.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,32.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.39,84,
IMITREX 6MG/0.5ML,3200393,CDM,636,RC,J3030,HCPCS,both,,,140.5,105.38,,112.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.54,140.5,
CLOBAZAM,2800169,CDM,300,RC,80154,HCPCS,outpatient,,,141,105.75,,112.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.74,112.8,
NH SUBSEQ VISIT,6200473,CDM,510,RC,99307,HCPCS,outpatient,,,141,105.75,,112.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.74,112.8,
KIDMED ENCOUNTER,6300102,CDM,521,RC,T1015,HCPCS,outpatient,,,141,105.75,,112.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.74,112.8,
FERRLECIT 62.5MG/5ML **DO NOT USE,3200306,CDM,636,RC,J2916,HCPCS,both,,,141.5,106.13,,113.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.94,141.5,
ESTROGEN LEVEL TOTAL,2800265,CDM,301,RC,82672,HCPCS,outpatient,,,142,106.5,,113.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.85,113.6,
ESTROGEN LEVEL TOTAL URINE,2800266,CDM,301,RC,82672,HCPCS,outpatient,,,142,106.5,,113.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.85,113.6,
EVAL FOR FITTING OF VOICE PROSTHETIC,5100633,CDM,440,RC,92597GN,HCPCS,outpatient,,,142,106.5,,113.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.14,113.6,
ELECTROCARDIOGRAM (EKG),5500001,CDM,730,RC,93005,HCPCS,outpatient,,,142,106.5,,113.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,113.6,
SFMC LACOSAMIDE LEVEL,2801395,CDM,302,RC,80235,HCPCS,outpatient,,,142.5,106.88,,114,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.55,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,114,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.55,114,
LAMICTAL LEVEL,2800397,CDM,302,RC,80175,HCPCS,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,114.4,
LAMOTRIGINE,2800398,CDM,301,RC,80299,HCPCS,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,114.4,
TESTOSTERONE FREE,2800598,CDM,301,RC,84402,HCPCS,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.73,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.73,114.4,
SFMC TESTOSTERONE FREE & TOTAL,2801161,CDM,301,RC,84402,HCPCS,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.73,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.11,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.47,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.73,114.4,
SFMC LAMICTAL LEVEL,2801220,CDM,302,RC,80175,HCPCS,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,114.4,
EMG 1 EXT,5600010,CDM,922,RC,95860,HCPCS,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.54,171.6,
REPETIT/NERVE STIMUL EACH NERVE,5600026,CDM,922,RC,95937,HCPCS,outpatient,,,143,107.25,,114.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.54,214.92,
TX-INSERT NON-INDWELL BLADDER CATH,1600006,CDM,761,RC,51701,HCPCS,outpatient,,,144,108,,115.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.95,171.6,
SFMC CPT 80342 CHG ONLY,2801373,CDM,301,RC,80342,HCPCS,outpatient,,,144,108,,115.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,115.2,
SOLU CORTEF 1000MG,3200791,CDM,636,RC,J1720,HCPCS,both,,,144,108,,115.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.95,144,
FACTOR 8 ANTIGEN,2800272,CDM,305,RC,83520,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,116,
HALDOL - HALOPERIDOL,2800318,CDM,300,RC,80173,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.89,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.51,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.89,116,
SFMC HLA B-27,2800358,CDM,302,RC,86812,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,91.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.14,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.9,116,
LEGIONAIRES TITER,2800404,CDM,302,RC,86713,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,54.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.3,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,116,
MEXITIL LEVEL,2800426,CDM,301,RC,80299,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,116,
NEURONTIN,2800445,CDM,301,RC,80171,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.83,116,
ROSEOLA IGG AB,2800544,CDM,302,RC,86790,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,39.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,116,
SIROLIMUS LEVEL,2800562,CDM,301,RC,80299,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,116,
TICLID,2800606,CDM,301,RC,80299,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,116,
TRILEPTAL LEVEL,2800616,CDM,301,RC,80183,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,116,
HLA B5701,2800897,CDM,302,RC,81381,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,362.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,362.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,84.95,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,254.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,362.39,
TESTOSTERONE WOMEN CHILDREN,2800898,CDM,301,RC,84403,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.9,116,
HLA DRB1,2801006,CDM,302,RC,81376,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,321.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,321.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,61.11,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,158.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,122.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,183.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,321.85,
HLA B INTERMEDIATE RESOLUTION,2801007,CDM,302,RC,81373,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,293.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,293.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,293.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.71,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,165.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,165.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,165.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,165.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,165.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,165.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,127.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.14,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,293.25,
SFMC TESTOSTERONE TOTAL,2801135,CDM,301,RC,84403,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,91.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.9,116,
SFMC TRILEPTAL LEVEL,2801238,CDM,301,RC,80183,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.62,116,
SFMC NEURONTIN,2801294,CDM,301,RC,80171,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.83,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.17,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.67,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.83,116,
DIPRIVAN 1% 100ML,3200253,CDM,636,RC,J2704,HCPCS,both,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,145,
PRIMAXIN 500MG INJ,3200698,CDM,636,RC,J0743,HCPCS,both,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,145,
ALBUMIN 25% 50ML,3202021,CDM,636,RC,P9047,HCPCS,both,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.08,145,
PR CT CHEST WITHOUT,4310013,CDM,972,RC,7125026,HCPCS,outpatient,,,145,108.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,87,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,87,87,
UNNA BOOT,6100090,CDM,521,RC,29580,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,379.9,
EXCISION OF LINGUAL FRENUM,6100095,CDM,521,RC,41115,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,2051.58,
NW PT HOME VISIT LEVEL 2,6100477,CDM,522,RC,99342,HCPCS,outpatient,,,145,108.75,,116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,58.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.35,116,
FB REMOVAL,6100165,CDM,521,RC,69205,HCPCS,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,3710.83,
FB REMOVAL,6300171,CDM,972,RC,69205,HCPCS,outpatient,,,146,109.5,,,,,,other,Not separately reimbursable for physician setting,62.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,92.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,87.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,92.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,92.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,92.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,92.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,92.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,147.54,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,92.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,129.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.19,147.54,
PREV MED EST AGE 40-64,6900093,CDM,982,RC,99396,HCPCS,outpatient,,,146,109.5,,,,,,other,Not separately reimbursable for physician setting,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,87.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,90.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,90.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,90.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,90.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,144.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,90.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,126.85,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.03,144.98,
AZACTAM 1GM INJ,3200052,CDM,636,RC,J0457,HCPCS,both,,,146.5,109.88,,117.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.95,146.5,
RAPID STREPT,2800527,CDM,302,RC,87651,HCPCS,outpatient,,,147,110.25,,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,80.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,123.94,
ACETAMINOPHEN SEND OUT,2800020,CDM,301,RC,G6039,HCPCS,outpatient,,,147.5,110.63,,118,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.13,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.35,118,
EMG CRANIAL BILAT,5600014,CDM,922,RC,95868,HCPCS,outpatient,,,147.5,110.63,,118,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.35,413.89,
17 KETOSTEROIDS 3,2800894,CDM,300,RC,83498,HCPCS,outpatient,,,148,111,,118.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,81.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.58,118.4,
MM Screening Dig Breast Tomosynt BIL,4001161,CDM,403,RC,77063,HCPCS,outpatient,,,148,111,,118.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.06,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.87,118.4,
IND/THERAPY 20-30MIN,6600006,CDM,914,RC,90804,HCPCS,outpatient,,,148,111,,118.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.56,118.4,
ANTI DIURETIC HORMONE,2800070,CDM,302,RC,83930,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.61,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.3,120,
PLASMINOGEN,2800478,CDM,302,RC,85420,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3.26,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,8.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,8.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.26,120,
PSA FREE,2800509,CDM,301,RC,84154,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.91,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.19,120,
SULFONYLUREA FOR HYPOGLYCEMICS,2800584,CDM,301,RC,80376,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.97,120,
THC CONFIRMATION - BLOOD,2800840,CDM,300,RC,80307,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
CYTOPATH EVAL FINAL REPORT,2800938,CDM,301,RC,88173,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,155.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,121.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,121.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.47,100,,,fee schedule,100% UHC fee schedule for outpatient setting,121.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.24,155.45,
Immunohisto/cyto chem 1st st,2800941,CDM,301,RC,G0461,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
Immunohisto/cyto chem add,2800942,CDM,301,RC,G0462,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
EXTRACTABLE NUCLEAR ANTIGEN PANEL,2800999,CDM,302,RC,86235,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,120,
21 HYDROXYLASE,2801004,CDM,300,RC,83519,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.33,120,
MYCOBACTERIUM TUBERCULOSIS NAA,2801033,CDM,306,RC,87556,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.84,123.94,
SFMC HEP C QUANTITATIVE RNA,2801325,CDM,302,RC,87522,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.42,151.24,
TMPT ENZYME ACTIVITY,2801425,CDM,301,RC,82657,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.08,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.08,120,
"MONKEYPOX, DNA, PCR",2801438,CDM,300,RC,87593,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,38.48,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38.48,120,
BB ELUTION PREP,3000022,CDM,300,RC,86860,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.6,232.4,
PROTAMINE SULFATE 250MG INJ,3200713,CDM,636,RC,J2720,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
FERRIC GLUCONATE 62.5MG/5ML,3207754,CDM,636,RC,J2916,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
MANNITOL 20 % 500 ML,3207867,CDM,636,RC,J2150,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
TISSUE MARKER IMPLANTABLE,4001078,CDM,278,RC,A4648,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
DO NOT USE,4001151,CDM,402,RC,76999TC,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PR XR KNEE ARTHROGRAM RT,4010076,CDM,972,RC,7358026RT,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR MM MAMMOGRAM DIAG BIL DIGITAL,4010086,CDM,972,RC,G020426,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR XR UPPER GI SERIES,4010129,CDM,972,RC,7424026,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR ESOPHOGRAM DOUB CONT,4011154,CDM,972,RC,7422126,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US AORTA COMPLETE,4110002,CDM,972,RC,7677026,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US GUIDED NEEDLE PLACEMENT/SURGICAL,4110018,CDM,972,RC,7694226,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US OB EACH ADDITONAL GESTATIONAL,4110022,CDM,972,RC,7681026,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US PELVIS NON OB COMPLETE,4110024,CDM,972,RC,7685626,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US RENAL COMPLETE,4110025,CDM,972,RC,7677026,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US RETROPERITENEAL SP COMPLETE,4110026,CDM,972,RC,7677026,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US SCROTUM/TESTICULAR,4110027,CDM,972,RC,7687026,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US TRANSRECTAL,4110031,CDM,972,RC,7687226,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US TRANSVAG PELVIS,4110032,CDM,972,RC,7683026,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US BREAST COMPLETE RT,4110051,CDM,972,RC,7664126RT,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR US BREAST COMPLETE LT,4110052,CDM,972,RC,7664126LT,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
MRI MULTIHANCE 15ML,4200030,CDM,636,RC,A9576,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
PR INJECTION JOINT  WITH CONTRAST,4210068,CDM,972,RC,23350,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,93.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.04,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.04,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.04,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.04,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,93.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,93.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,49.04,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.04,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,93.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,78.46,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,49.04,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,68.66,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.04,93.35,
PR NM LUNG COMPLETE VQ,4400018,CDM,972,RC,7859826,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
NM PH CCK KINOVAC-SINCALIDE PER DOSE,4400031,CDM,343,RC,J2805,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PR NM BILIARY LIVER FUNCTION,4410001,CDM,972,RC,7822726,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM BILLIARY SCAN,4410002,CDM,972,RC,7822626,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM BILLIARY SCAN WITH CCK,4410003,CDM,972,RC,7822726,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM BONE WHOLE BODY,4410007,CDM,972,RC,7830626,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM EJECTION FRACTION,4410011,CDM,972,RC,7845426,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM GASTRIC EMPTY STUDY,4410012,CDM,972,RC,7826426,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM LIVER SPECT,4410013,CDM,972,RC,7820526,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM LIVER VASCULAR FLOW STUDY,4410014,CDM,972,RC,7820626,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM LOCALIZATION-GALLIUM WHOLE BODY,4410016,CDM,972,RC,7880626,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM LUNG VENTILATION MULTIPLE PROJECT,4410020,CDM,972,RC,7859826,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
PR NM VENOGRAM W/ISOTOPE BILATERAL,4410063,CDM,972,RC,7845826,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
EVALUATE PT USE OF INHALER,5200100,CDM,270,RC,94664,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.33,283.02,
SIX MINUTE WALK TEST,5200106,CDM,460,RC,94618TC,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
"CNP, CONTIN NEG PRESSURE VENT",5200112,CDM,410,RC,94662,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,822.79,
ACT(CATH LAB),5800014,CDM,271,RC,85347,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.14,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.56,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.42,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.14,120,
I&D OF HEMATOMA SIMPLE,6000105,CDM,521,RC,10140,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,3001.14,
PUNCH BIOPSY LESION>5CM,6000109,CDM,521,RC,11100,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
SHAVING LESION OVER 2 CM,6000117,CDM,521,RC,11308,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,551.37,
WEDGE EXCISION OF NAIL,6000131,CDM,521,RC,11765,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,551.37,
REMOVAL IMPLANON IMPLANTABLE CONTRACEPTI,6000133,CDM,521,RC,11976,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,959.14,
"REPAIR, INTERMEDIATE 7.6 CM TO 12.5 CM",6000138,CDM,521,RC,12004,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,375.41,
DESTRUCTION OF BENIGN LESIONS,6000148,CDM,521,RC,17110,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,266.88,
JOINT INJECTION,6000153,CDM,521,RC,20610,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,429.76,
PELVIC YEARLY EXAM,6000160,CDM,521,RC,57410,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,4178.79,
ROTAVIRUS PENTAVALENT 3 DOSE LIVE,6000215,CDM,636,RC,90680,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
EST LEVEL 4 OV,6000263,CDM,521,RC,99214,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,224.87,
DEBRIDMENT,6000330,CDM,521,RC,11042,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,990.21,
FINE NEEDLE ASPIRATION W/O IMAGING GUIDA,6100042,CDM,521,RC,10021,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,932.28,
I&D OF HEMATOMA SIMPLE,6100047,CDM,521,RC,10140,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,3001.14,
PUNCH BIOPSY LESION>5CM,6100051,CDM,521,RC,11100,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
SHAVING LESION OVER 2 CM,6100058,CDM,521,RC,11308,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,551.37,
REMOVAL IMPLANON IMPLANTABLE CONTRACEPTI,6100069,CDM,521,RC,11976,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,959.14,
DESTRUCTION OF BENIGN LESIONS,6100078,CDM,521,RC,17110,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,266.88,
JOINT INJECTION,6100080,CDM,521,RC,20610,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,429.76,
DESTROY VULVA LESION,6100112,CDM,521,RC,56501,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3411.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3411.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3411.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,3411.63,
PELVIC YEARLY EXAM,6100121,CDM,521,RC,57410,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,4178.79,
ENDOMETRIAL SAMPLING,6100139,CDM,521,RC,58100,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,263.25,
XR LUMBAR SPINE 4 OR MORE VIEWS,6100188,CDM,320,RC,72110,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.89,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,174.35,
NSG HOME ADMIT II,6100239,CDM,522,RC,99325,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NSG HOME VISIT III,6100243,CDM,522,RC,99336,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
ROTAVIRUS IMMUNIZATION,6100270,CDM,636,RC,90680,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
CONSULT OV LEVEL III - SURG,6100336,CDM,521,RC,99243,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
CRITICAL CARE 30MIN,6100353,CDM,521,RC,99292,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,842.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,842.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,842.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,842.52,
SB SUBSEQUENT LEVEL 4,6100359,CDM,524,RC,99310,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
EST LEVEL 4 OV,6100395,CDM,521,RC,99214,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,224.87,
CONSULT OV LEVEL III,6100409,CDM,521,RC,99243,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
SHAVE LESION <1500.6CM,6100411,CDM,521,RC,11301,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,266.88,
HEP B VACCINE,6100442,CDM,636,RC,90746,HCPCS,both,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,150,
"REPAIR, INTERMEDIATE 7.6 CM TO 12.5 CM",6100475,CDM,521,RC,12004,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,375.41,
EST PT HOME VISIT LEVEL 3,6100482,CDM,522,RC,99348,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NH ADMIT LEVEL 2,6100493,CDM,525,RC,99305,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NH SUBSEQUENT LEVEL 4,6100499,CDM,525,RC,99310,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
KUB XRAY 2V,6100567,CDM,320,RC,74019TC,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
EMERGENCY ROOM,6200004,CDM,450,RC,99282,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,206.44,
ASPIRATION/INJECTION OF GANGLIONCYST,6200062,CDM,360,RC,20612,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,429.76,
BIOSPY OF SKIN EACH ADD LESION,6200321,CDM,361,RC,11101,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
DEBRIDEMENT TISSUE FROM WOUND W/O ANES,6200425,CDM,510,RC,97602,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,302.24,
DRAINAGE OF BREAST LESION,6200515,CDM,360,RC,19000,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,959.13,
REMOVAL OF PRESSURE SORE,6200582,CDM,360,RC,15999,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,959.13,
DESTRUCTION OF BENIGN LESIONS,6300067,CDM,521,RC,17110,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,266.88,
EXCISION-LESION,6300077,CDM,521,RC,11400,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,959.13,
FAMILY PSYCH WITH PATIENT,6300079,CDM,972,RC,90847,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,156.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,137.35,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,75.36,156.98,
FINE NEEDLE ASPIRATION W/O IMAGING GUIDA,6300080,CDM,521,RC,10021,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,932.28,
IND PSYCHOTHERAPY 45-50 MIN,6300091,CDM,972,RC,90834,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,56.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,87.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,87.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,87.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,87.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,56.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,56.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,87.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,87.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,56.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,139.41,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,87.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,121.98,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,56.16,139.41,
PSYCH DIAG INTERVIEW EXAM,6300117,CDM,521,RC,90801,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
SHAVING LESION OVER 2 CM,6300128,CDM,521,RC,11308,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,551.37,
WEDGE EXCISION OF NAIL,6300132,CDM,521,RC,11765,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,551.37,
TEAM CONFERENCE/CASE MANAGER >30MIN,6300177,CDM,972,RC,99368,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,34.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,34.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,34.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,34.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,34.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,34.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,54.82,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,34.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,47.96,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,34.26,90,
SUBSEQUENT HOSPITAL LEVEL 3,7000005,CDM,987,RC,99233,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,185.94,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,116.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,162.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,66.52,185.94,
INPATIENT D/C 30 MINS OR LESS,7000006,CDM,987,RC,99238,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,125.18,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,78.24,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,109.54,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,45.85,125.18,
SB ADMIT LEVEL II,7000017,CDM,524,RC,99305,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
SB VISIT LEVEL III,7000023,CDM,524,RC,99310,HCPCS,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
SWING BED SUBSEQUENT-10 MINS,7000029,CDM,982,RC,99308,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,41.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,41.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,41.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,41.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,114.67,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,71.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.34,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,41.83,114.67,
OBSERVATION SUBSEQUENT 35 MINS,7000036,CDM,982,RC,99226,HCPCS,outpatient,,,150,112.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,90,90,
SCREW 2.3MM BONE 12MM,890082,CDM,278,RC,C1713,HCPCS,both,,,150.7,113.03,,120.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.64,869.4,
SCREW 2.3MM BONE 8MM,890083,CDM,278,RC,C1713,HCPCS,both,,,150.7,113.03,,120.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.64,869.4,
SCREW 2.3MM BONE 9MM,890084,CDM,278,RC,C1713,HCPCS,both,,,150.7,113.03,,120.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.64,869.4,
SCREW 2.3MM BONE 11MM,890085,CDM,278,RC,C1713,HCPCS,both,,,150.7,113.03,,120.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.64,869.4,
REMOVE SUTURES DIFF SURGEON,6200571,CDM,360,RC,15851,HCPCS,outpatient,,,151,113.25,,120.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,113.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.76,2550.71,
K-WIRE,890066,CDM,278,RC,C1713,HCPCS,both,,,151.2,113.4,,120.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.84,869.4,
XR GB IN OR ADDIT FILMS,4000065,CDM,320,RC,74301TC,HCPCS,outpatient,,,152,114,,121.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.6,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.16,121.6,
APP CAST; FINGER,6100703,CDM,521,RC,29086,HCPCS,outpatient,,,152,114,,121.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,61.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.16,215.42,
URINE FREE HEMOGLOBIN,2800629,CDM,301,RC,83069,HCPCS,outpatient,,,152.5,114.38,,122,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,83.88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.95,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.97,122,
ROCEPHIN 500MG,3200762,CDM,636,RC,J0696,HCPCS,both,,,152.5,114.38,,122,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.37,152.5,
HYDROXYPROGESTERONE 17,2800369,CDM,301,RC,83498,HCPCS,outpatient,,,153,114.75,,122.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,84.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.58,122.4,
SFMC HYDROXYPROGESTERONE 17,2801250,CDM,301,RC,83498,HCPCS,outpatient,,,153,114.75,,122.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,95.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.58,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,84.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.17,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.58,122.4,
MM Diag Dig Breast Tomosynthesis UNI 3D,4001159,CDM,401,RC,77061,HCPCS,outpatient,,,153,114.75,,122.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.15,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.87,146.27,
HOME HEALTH PATIENT CERTIFICATION INIT,6200387,CDM,510,RC,G0180,HCPCS,outpatient,,,153,114.75,,122.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,61.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.57,122.4,
DO NOT USE,4200059,CDM,610,RC,,,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
CYCLOSPORIN,2800228,CDM,301,RC,80158,HCPCS,outpatient,,,153.5,115.13,,122.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,84.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,122.8,
SFMC CYCLOSPORIN,2801256,CDM,301,RC,80158,HCPCS,outpatient,,,153.5,115.13,,122.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,84.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.02,122.8,
SFMC CPT 87118 CHG AFB CULTURE ID,2801371,CDM,306,RC,87118,HCPCS,outpatient,,,153.5,115.13,,122.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,84.43,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.61,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.6,122.8,
OBS ADMIT LEV II,6100320,CDM,982,RC,99219,HCPCS,outpatient,,,154,115.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,92.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,92.4,92.4,
PER COMP (AGE 18-39),6100377,CDM,521,RC,99395,HCPCS,outpatient,,,154,115.5,,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,61.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,61.97,123.2,
KETO-STERIODS TOTAL,2800392,CDM,301,RC,83586,HCPCS,outpatient,,,154.5,115.88,,123.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.21,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,84.98,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.64,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.4,123.6,
AC ADM LEVEL II,6100323,CDM,987,RC,99222,HCPCS,outpatient,,,155,116.25,,,,,,other,Not separately reimbursable for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,93,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,203.54,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,178.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,85.35,203.54,
INITIAL HOSPITAL CARE LEVEL 2,7000001,CDM,987,RC,99222,HCPCS,outpatient,,,155,116.25,,,,,,other,Not separately reimbursable for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,93,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,203.54,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,178.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,85.35,203.54,
RAJI CELL,2800526,CDM,302,RC,86332,HCPCS,outpatient,,,156,117,,124.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,86.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,86.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,86.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.18,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,85.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,117,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.18,124.8,
ESTRADIOL,2800263,CDM,301,RC,82670,HCPCS,outpatient,,,157,117.75,,125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,98.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,86.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.97,125.6,
SFMC ESTRADIOL,2801124,CDM,301,RC,82670,HCPCS,outpatient,,,157,117.75,,125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,98.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,86.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.97,125.6,
SFMC ESTROGEN,2801197,CDM,301,RC,82672,HCPCS,outpatient,,,157,117.75,,125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,86.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,28.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,117.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,21.7,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.85,125.6,
DO NOT USE,4000025,CDM,320,RC,74000TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR CHEST SPECIAL VIEW EX.DECUB,4000041,CDM,324,RC,71035TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR CLAVICLE COMPLETE RT,4000043,CDM,320,RC,73000TCRT,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR ELBOW COMPLETE 3 VIEW RT,4000049,CDM,320,RC,73080RTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR FOOT-2 VIEWS RT,4000061,CDM,320,RC,73620TCRT,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR FOREARM 2 VIEWS RT,4000062,CDM,320,RC,73090TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR WHOLE BODY CHILD SINGLE VIEW,4000063,CDM,320,RC,76010TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR HAND 2 VIEWS RT,4000066,CDM,320,RC,73120RTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR HEEL MIN 2 VIEWS RT,4000068,CDM,320,RC,73650RTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR IVP  RETROGRADE CYSTOURETHAGRAM,4000073,CDM,320,RC,74450TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR KNEE 2 VIEW/PATELLA RT,4000074,CDM,320,RC,73560TCRT,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR LOWER EXTREMITY INFANT MIN 2 VIEWS RT,4000079,CDM,320,RC,73592TCRT,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR NASAL BONES COMP MIN 3 VIEWS,4000098,CDM,320,RC,70160TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR PELVIS 1 OR 2 VIEW,4000100,CDM,324,RC,72170TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR SACRUM AND OR COCCYX MIN 2 VIEW,4000104,CDM,320,RC,72220TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR SELLA TURCICA,4000108,CDM,320,RC,70240TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR SHOULDER 1 VIEW RT,4000109,CDM,320,RC,73020TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR SINUSES <3 VIEWS,4000112,CDM,320,RC,70210TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR SOFT TISSUE NECK,4000117,CDM,320,RC,70360TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR SPINE SINGLE VIEW,4000118,CDM,324,RC,72020TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR TOE MIN 2 VIEWS RT,4000126,CDM,320,RC,73660RTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR WRIST 2 VIEWS RT,4000134,CDM,320,RC,73100RTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR ZYGOMATIC ARCHES <3 VIEWS,4000136,CDM,320,RC,70140TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR CLAVICLE COMPLETE LT,4000142,CDM,320,RC,73000LTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR ELBOW COMPLETE 3 VIEW LT,4000143,CDM,320,RC,73080LTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR FOREARM 2 VIEWS LT,4000148,CDM,320,RC,73090LTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR HAND 2 VIEWS LT,4000149,CDM,320,RC,73120LTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR HEEL MIN 2 VIEWS LT,4000151,CDM,320,RC,73650LTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR KNEE 2 VIEW/PATELLA LT,4000154,CDM,320,RC,73560LTTC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR LOWER EXTREMITY INFANT MIN 2 VIEWS LT,4000157,CDM,320,RC,73592TCLT,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR SHOULDER 1 VIEW LT,4000161,CDM,320,RC,73020TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR TOE MIN 2 VIEWS LT,4000166,CDM,320,RC,73660TCLT,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR WRIST 2 VIEWS LT,4000167,CDM,320,RC,73100TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR FOOT-2 VIEWS LT,4000183,CDM,320,RC,73620TCLT,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
XR ABD-1 VIEW (KUB)*,4001143,CDM,320,RC,74018TC,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,126.4,
EMG 2 EXT,5600011,CDM,922,RC,95861,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,171.6,
DRESSING CHANGE UNDER ANESTHESIA,6200098,CDM,360,RC,15852,HCPCS,outpatient,,,158,118.5,,126.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.58,858.61,
RESPITORY FLOW VOL LOOP,5200066,CDM,460,RC,94375,HCPCS,outpatient,,,159,119.25,,127.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.98,413.91,
CLOMIPRAMINE SERUM,2800167,CDM,300,RC,80335,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.95,128,
17 KETOSTEROIDS,2800892,CDM,300,RC,82157,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,103.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,103.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,103.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.64,128,
SPECIAL STAINS GRP 2,2800930,CDM,301,RC,88313,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,61.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.28,128,
SFMC NICOTINE URINE QUANTITATIVE,2801315,CDM,301,RC,80323,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.08,128,
PR US ART DOP COMPLETE BILAT LOWER EXT,4110003,CDM,972,RC,9392526,HCPCS,outpatient,,,160,120,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,96,96,
PR US ART DOP COMPLETE BILAT UPPER EXT,4110004,CDM,972,RC,9393026,HCPCS,outpatient,,,160,120,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,96,96,
PT EVALUATION OR RE EVALUATION,5197161,CDM,420,RC,97161,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,163.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,163.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,163.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,95.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,95.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,153.41,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,95.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.94,163.24,
PT RE EVALUATION OF PT EST PLAN OF CARE,5197164,CDM,424,RC,97164GP,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,128,
"EXCISION, BENIGN LESION 0.6CM - 1.0CM",6000121,CDM,521,RC,11401,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,786.48,
PER COMP (AGE 18-39),6000276,CDM,521,RC,99395,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,128,
DTAP/HIB,6100284,CDM,636,RC,90721,HCPCS,both,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,160,
SB SUBSEQUENT LEVEL 2,6100358,CDM,524,RC,99308,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,128,
NW PT HOME VISIT LEVEL 3,6100478,CDM,522,RC,99343,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,128,
"EXCISION, BENIGN LESION 0.6CM - 1.0CM",6100489,CDM,521,RC,11401,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,786.48,
BIOPSY OF EXTERNAL EAR,6200489,CDM,360,RC,69100,HCPCS,outpatient,,,160,120,,128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.38,786.48,
PR US ART DOP COMPLETE BILAT LOWER EXT,41100003,CDM,972,RC,9392526,HCPCS,outpatient,,,160,120,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,96,96,
PR US ART DOP COMPLETE BILAT UPPER EXT,41100004,CDM,972,RC,9393026,HCPCS,outpatient,,,160,120,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,96,96,
DDAVP 4MCG/ML 1ML AMP,3200207,CDM,636,RC,J2597,HCPCS,both,,,160.25,120.19,,128.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.22,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.15,160.25,
CYANIDE LEVEL,2800226,CDM,301,RC,82600,HCPCS,outpatient,,,161,120.75,,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,88.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.22,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.22,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.22,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.22,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.22,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.22,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.69,128.8,
OFFICE OR OTHER O/P CONSULT-LEVEL 2,6200028,CDM,510,RC,99202,HCPCS,outpatient,,,161,120.75,,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,134.33,
OFFICE OR OTHER OP CONSULT-LIMITED,6200402,CDM,360,RC,99242,HCPCS,outpatient,,,161,120.75,,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.79,128.8,
MMR,6900046,CDM,982,RC,90707,HCPCS,outpatient,,,161,120.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,96.6,96.6,
VANCOMYCIN 1.5 GM/300ML  PREMIX,3206083,CDM,636,RC,J3370,HCPCS,both,,,162,121.5,,129.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.19,162,
GUIDE WIRE HI-TORQUE BALANCE MIDDLEWEIGH,5890014,CDM,278,RC,C1769,HCPCS,both,,,164,123,,131.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.99,164,
TEST LVL II,6200588,CDM,510,RC,99213,HCPCS,outpatient,,,164,123,,131.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38,154.55,
GUIDEWIRE WHISPER,90000738,CDM,278,RC,C1769,HCPCS,both,,,164,123,,131.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.99,164,
SCREW 2.7MM NON LOCKING 20MM,890100,CDM,278,RC,C1713,HCPCS,both,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,869.4,
SCREW 2.7MM NON LOCKING 12MM,890101,CDM,278,RC,C1713,HCPCS,both,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,869.4,
SCREW 2.7MM NON LOCKING 22MM,890102,CDM,278,RC,C1713,HCPCS,both,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,869.4,
HISTAMINE DETERMINATION BLOOD,2800916,CDM,301,RC,83088,HCPCS,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,104.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.76,132,
ANTI-GQ1b,2801026,CDM,306,RC,83520,HCPCS,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,132,
BB RARE ANTIGEN TYPE FEE,3000042,CDM,300,RC,86905,HCPCS,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,479.01,
LEVAQUIN 500MG 100ML PREMIX,3200460,CDM,636,RC,J1956,HCPCS,both,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,165,
PROTOPAM CHLORIDE-1GM/20ML,3200719,CDM,636,RC,J2730,HCPCS,both,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,165,
BOOSTRIX (TDaP),3201598,CDM,636,RC,90715,HCPCS,both,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,165,
ACETAMINOPHEN IV 1000MG,3207544,CDM,636,RC,J0131,HCPCS,both,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,165,
US GUIDANCE FOR VASCULAR ACCESS,4100016,CDM,402,RC,76937TC,HCPCS,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,132,
INCISION OF THROMBOSED HEMORRHOID,6000158,CDM,521,RC,46083,HCPCS,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,664.5,
INCISION OF THROMBOSED HEMORRHOID,6100097,CDM,521,RC,46083,HCPCS,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,664.5,
INCISION OF THROMBOSED HEMORRHOID,6300089,CDM,521,RC,46083,HCPCS,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,664.5,
SFMC CARNITINE URINE TOTAL AND FREE,2800141,CDM,301,RC,82379,HCPCS,outpatient,,,166,124.5,,132.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,91.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.3,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.43,132.8,
URINE 24 HR HISTAMINE,2800626,CDM,301,RC,83088,HCPCS,outpatient,,,166,124.5,,132.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,104.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,91.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,124.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.24,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.76,132.8,
CRYOSURGERY,6900010,CDM,982,RC,17000,HCPCS,outpatient,,,166,124.5,,,,,,other,Not separately reimbursable for physician setting,46.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,46.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,51.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,82.38,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,51.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,46.04,99.6,
CRYOSURGERY 2-14 LESION,6900011,CDM,982,RC,17003,HCPCS,outpatient,,,166,124.5,,,,,,other,Not separately reimbursable for physician setting,4.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,4.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,4.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,4.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,3.1,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,1.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.72,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.94,99.6,
SCREW 3.5MM NON LOCKING 40MM,890179,CDM,278,RC,C1713,HCPCS,both,,,166.6,124.95,,133.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.04,869.4,
LIPOPROTEIN A,2800414,CDM,301,RC,83695,HCPCS,outpatient,,,167,125.25,,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,91.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,14.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.16,133.6,
VITAMIN D 25 OH,2800652,CDM,301,RC,82306,HCPCS,outpatient,,,167,125.25,,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,91.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.8,133.6,
SFMC VITAMIN D 25(OH),2801119,CDM,301,RC,82306,HCPCS,outpatient,,,167,125.25,,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.8,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,91.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.48,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.8,133.6,
AVULSION OF NAIL PLATE SIMPLE SINGLE,6200063,CDM,360,RC,11730,HCPCS,outpatient,,,167,125.25,,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.2,266.88,
SHAVE SKIN LESION 0.6CM TO 1.0CM,6200286,CDM,360,RC,11306,HCPCS,outpatient,,,167,125.25,,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.2,266.88,
CT BD NEXIVA HIGH PRESSURE CATHETER SET,4300001,CDM,270,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
FNA W/IMAGE EACH ADDITIONAL LESION,6200599,CDM,510,RC,10006,HCPCS,outpatient,,,167,125.25,,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,67.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.2,201.35,
BB MMA TEST #3,3000036,CDM,300,RC,86880,HCPCS,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,7.01,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.39,134.4,
PR CT BRAIN WITHOUT,4310010,CDM,972,RC,7045026,HCPCS,outpatient,,,168,126,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,100.8,100.8,
OT RE EVAL OF ESTABLISHED PLAN OF CARE,5100619,CDM,434,RC,97168GO,HCPCS,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
HOLTER MONITOR HOOK-UP TZ,5500006,CDM,731,RC,93228,HCPCS,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
ASPIRATION/INJ THYROID CYST,6200592,CDM,360,RC,60300,HCPCS,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,878.05,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,878.05,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,878.05,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,959.13,
PHARMACOLOGIC MANAG/REVIEW OF MEDICATION,6600010,CDM,914,RC,90862,HCPCS,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
DTAP/HBV/POLIO,6900052,CDM,982,RC,90723,HCPCS,outpatient,,,169,126.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,101.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,101.4,101.4,
SCREW 3.5MM NON-LOCKING 28MM,890142,CDM,278,RC,C1713,HCPCS,both,,,169.4,127.05,,135.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.17,869.4,
SCREW 3.5MM NON LOCKING 30MM,890178,CDM,278,RC,C1713,HCPCS,both,,,169.4,127.05,,135.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.17,869.4,
SCREW 3.5 NON LOCKING 10MM,890181,CDM,278,RC,C1713,HCPCS,both,,,169.4,127.05,,135.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.17,869.4,
SCREW 3.5MM NON-LOCKING 12MM,890061,CDM,278,RC,C1713,HCPCS,both,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.41,869.4,
SFMC HISTOPLASMA URINE ANTIGEN,2800918,CDM,301,RC,87305,HCPCS,outpatient,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,93.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.99,136,
SFMC M TUBERCULOSIS DNA PROBE,2801359,CDM,306,RC,87556,HCPCS,outpatient,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.84,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,93.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,54.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% UHC fee schedule for outpatient setting,41.68,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.84,136,
CONT INHALATION TX/MED EACH ADDT'L HR,5200027,CDM,410,RC,9464576,HCPCS,outpatient,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.41,136,
CPAP/BIPAP SUBSEQUENT,5600029,CDM,410,RC,94660,HCPCS,outpatient,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.41,283.02,
PREV MED AGE 40-64,6000277,CDM,521,RC,99396,HCPCS,outpatient,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.41,136,
PREV MED AGE 40-64,6100378,CDM,521,RC,99396,HCPCS,outpatient,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.41,136,
EST PT HOME VISIT LEVEL 4,6100483,CDM,522,RC,99349,HCPCS,outpatient,,,170,127.5,,136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,68.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.41,136,
PROTEIN ELECTROPHORESIS 24 HR URINE,2800497,CDM,300,RC,84166,HCPCS,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.91,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.18,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.91,136.8,
DHEA,2801164,CDM,301,RC,82626,HCPCS,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,32.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.63,136.8,
DIAMOX INJ 500 MG,3200237,CDM,636,RC,J1120,HCPCS,both,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.81,171,
RSV COLLECTION-NC,5200068,CDM,410,RC,94642,HCPCS,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.81,283.02,
SPUTUM COLLECTION-NO AEROSOL,5200073,CDM,410,RC,94642,HCPCS,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.81,283.02,
"XR SPINE, THORASIC 3 VIEW",6100702,CDM,320,RC,72072,HCPCS,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,75.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.81,174.35,
DUODENAL INTUBATION AND ASPIRATION DX,6200099,CDM,360,RC,43756,HCPCS,outpatient,,,171,128.25,,136.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,210.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,210.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,68.81,1220.05,
BONE AGE,4000001,CDM,320,RC,77072TC,HCPCS,outpatient,,,172,129,,137.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.6,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.21,137.6,
XR HAND MIN 3 VIEW RT,4000067,CDM,320,RC,73130TCRT,HCPCS,outpatient,,,172,129,,137.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.6,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.21,137.6,
XR SINUSES COMP MIN 3 VIEWS,4000113,CDM,320,RC,70220TC,HCPCS,outpatient,,,172,129,,137.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.6,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.21,137.6,
Removal foreign body from ear; w/o anest,6100730,CDM,521,RC,69200,HCPCS,outpatient,,,172,129,,137.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,129,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,69.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.21,171.6,
EAR LAVAGE,6900023,CDM,982,RC,69210,HCPCS,outpatient,,,172,129,,,,,,other,Not separately reimbursable for physician setting,30.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,32.08,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,103.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,32.08,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,32.08,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,32.08,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,30.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,30.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,32.08,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,32.08,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,30.33,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,51.33,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,32.08,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,44.91,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,30.33,103.2,
REMOVAL NON BIODEGRADABLE DRUG DELIVERY,600135,CDM,521,RC,11982,HCPCS,outpatient,,,173,129.75,,138.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.62,558.02,
"REMOVAL, NON BIODEGRADABLE DRUG DELIVERY",6000135,CDM,521,RC,11982,HCPCS,outpatient,,,173,129.75,,138.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.62,558.02,
"REMOVAL, NON BIODEGRADABLE DRUG DELIVERY",6100451,CDM,521,RC,11982,HCPCS,outpatient,,,173,129.75,,138.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.62,558.02,
PREOP PLACEMENT NEEDLE LOCAL WIREBREAST,6200235,CDM,360,RC,19290,HCPCS,outpatient,,,173,129.75,,138.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.62,138.4,
SCREW 2.3 LOCKING 9MM,890086,CDM,278,RC,C1713,HCPCS,both,,,173.8,130.35,,139.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.94,869.4,
SCREW 2.3MM LOCKING 12MM,890087,CDM,278,RC,C1713,HCPCS,both,,,173.8,130.35,,139.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.94,869.4,
SCREW 2.3MM LOCKING 10MM,890088,CDM,278,RC,C1713,HCPCS,both,,,173.8,130.35,,139.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.94,869.4,
SCREW 2.3MM LOCKING 8MM,890089,CDM,278,RC,C1713,HCPCS,both,,,173.8,130.35,,139.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,69.94,869.4,
DEBRIDEMENT BURN SMALL(LESS THAN5%),6200084,CDM,360,RC,16020,HCPCS,outpatient,,,174,130.5,,139.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,139.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.02,375.41,
ADM PNEUMOCOCCAL VACCINE,1400003,CDM,771,RC,G0009,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.54,140,
VACCINE ADMINISTRATION,1400093,CDM,771,RC,90471,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.19,140,
BB CELL SEPARATION,3000026,CDM,300,RC,86972,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,232.4,
AZACTAM 2GM INJ,3200053,CDM,636,RC,J0457,HCPCS,both,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,175,
CALCIUM DISODIUM VER AMP,3200104,CDM,636,RC,J0600,HCPCS,both,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5708.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5708.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5708.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5708.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5708.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5708.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9133.74,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5708.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8562.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,9133.74,
MEROPENEM 1GM/NSS 100ML,3203301,CDM,636,RC,J2185,HCPCS,both,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,175,
MEROPENEM 1 GM PREMIXED,3207057,CDM,636,RC,J2184,HCPCS,both,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,175,
XR ANKLE COMPLETE 3 VIEW  LT,4000141,CDM,320,RC,73610TCLT,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
PR XR COLON/AIR CONTRAST,4010044,CDM,972,RC,7428026,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
PR XR COLON/AIR CONTRAST,4010186,CDM,972,RC,7428026,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
CT PRESSURE RATED EXTENSION SET,4300052,CDM,270,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
CT STELLANT DUAL SYRING KIT,4300053,CDM,270,RC,,,outpatient,,,69,51.75,,55.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.77,55.2,
CT SWABBABLE TRANSFER SET,4300054,CDM,270,RC,,,outpatient,,,23,17.25,,18.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.26,18.4,
CT XDS DISPOSABLE INTERFACE,4300055,CDM,270,RC,,,outpatient,,,19,14.25,,15.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.65,15.2,
PR US OB > OR = 14 WEEKS,4110021,CDM,972,RC,7680526,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
PR US UPPER ABDOMEN COMPLETE,4110033,CDM,972,RC,7670026,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
PR NM QUANTITATIVE DIFF FUNCTION,4410048,CDM,972,RC,7858226,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
PR NM RENAL FLOW W/O PHARMACOLGIC INT,4410050,CDM,972,RC,7870726,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
NEW PT LEVEL 4 OV,6000255,CDM,521,RC,99204,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,224.87,
CAST SHORT ARM,6100085,CDM,521,RC,29085,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,215.42,
NSG HOME ADMIT III,6100240,CDM,522,RC,99326,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
SB ADMIT LEVEL 2,6100355,CDM,524,RC,99305,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
SB ADMIT LEVEL 3,6100356,CDM,524,RC,99306,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
NEW PT LEVEL 4 OV,6100388,CDM,521,RC,99204,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,224.87,
PROCEDURE-LEVEL 1 RADIOLOGY,4300070,CDM,360,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
PROCEDURE-LEVEL 2 RADIOLOGY,4300071,CDM,360,RC,,,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
NH ADMIT LEVEL 3,6100494,CDM,525,RC,99306,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
PEG REPLACEMENT,6200372,CDM,521,RC,43750,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
BX SKIN EACH SEPERATE/ADDITIONAL LESION,6200633,CDM,360,RC,11103,HCPCS,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.43,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,169.43,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,169.43,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,169.43,
PRO FEE IND/THERAPY 45-50 MIN,6600015,CDM,960,RC,90806,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
PRO FEE PSYCH DIAG INTERVIEW EXAM,6600018,CDM,960,RC,90801,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
INITIAL HOSPITAL CARE LEVEL 1,7000000,CDM,987,RC,99221,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,130.4,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,81.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,114.1,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.52,130.4,
SB ADMIT LEVEL III,7000018,CDM,982,RC,99306,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,99.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,175,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,175,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,175,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,175,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,175,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,175,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,280,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,175,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,245,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.9,280,
SWING BED SUBSEQUENT-25 MINS,7000030,CDM,982,RC,99309,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,55.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,55.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,55.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,102.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,55.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,164.26,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,102.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,143.72,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,55.56,164.26,
PR XR T-TUBE CHOLANGIOGRAM,40010127,CDM,972,RC,7432726,HCPCS,outpatient,,,175,131.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,105,105,
TX-INSERT TEMP INDWELL BLADDER CATH SIMP,1600007,CDM,761,RC,51702,HCPCS,outpatient,,,176,132,,140.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.82,171.6,
LACOSAMIDE SERUM,2800879,CDM,301,RC,82542,HCPCS,outpatient,,,176,132,,140.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,96.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.13,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.04,140.8,
"Insertion, non-biodegradable drug deliv",6100569,CDM,521,RC,11981,HCPCS,outpatient,,,176,132,,140.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.82,171.6,
LEUKEMIA PROFILE,2800943,CDM,311,RC,88184,HCPCS,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,132.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,132.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,132.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,54.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,54.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.87,479.01,
PROCTOSIGMOIDOSCOPY DIAGNOSTIC,6200238,CDM,360,RC,45300,HCPCS,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.22,1228.22,
PSYCHOTHERAPY GROUP,6690853,CDM,915,RC,90853,HCPCS,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.41,205.08,
PSYCHOTHERAPY GROUP LA HC CONNECT,6690854,CDM,915,RC,90853,HCPCS,outpatient,,,177,132.75,,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,71.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.41,205.08,
CATECHOLAMINES  24 HR URINE,2800144,CDM,300,RC,82384,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.62,142.4,
SFMC CATECHOLAMINES  24 HR URINE,2801230,CDM,300,RC,82384,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.62,142.4,
BV & YEAST ASSOCIATED CPT,2801426,CDM,306,RC,87905,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,38.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.11,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.11,142.4,
XR A/C JOINTS W WEIGHT ONLY,4000022,CDM,320,RC,73050TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
DO NOT USE,4000023,CDM,320,RC,74020TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR ANKLE COMPLETE 3 VIEW  RT,4000028,CDM,320,RC,73610TCRT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
DO NOT USE,4000038,CDM,324,RC,71020TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
DO NOT USE,4000040,CDM,324,RC,71022TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
DO NOT USE,4000042,CDM,324,RC,71021TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR FACIAL BONES COMP MIN 3 VIEWS,4000052,CDM,320,RC,70150TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR FEMUR 2 VIEW RT,4000053,CDM,320,RC,73552TCRT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR FOOT COMP MIN 3 VIEWS RT,4000060,CDM,320,RC,73630TCRT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR HIP BILATERAL MIN 2 VIEW,4000069,CDM,320,RC,73522TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR HIP UNILATERAL MIN 2 VIEW RT,4000070,CDM,320,RC,73502TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR HUMERUS MIN 2 VIEW RT,4000071,CDM,320,RC,73060TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR KNEE 3 VIEW RT,4000075,CDM,320,RC,73562TCRT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
DO NOT USE,4000077,CDM,320,RC,73564RTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR MANDIBLE COMP MIN 4 VIEW,4000090,CDM,320,RC,70110TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR MASTOIDS COMP MIN 3 VIEW,4000091,CDM,320,RC,70130TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR ORBITS COMP MIN 4 VIEWS,4000099,CDM,320,RC,70200TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR RIBS UNILATERAL 2 VIEW RT,4000102,CDM,324,RC,71100RTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR S.I JOINTS 3 OR MORE VIEWS BILATERAL,4000103,CDM,324,RC,72202TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SCANOGRAM BONE LENGTH,4000105,CDM,320,RC,77073TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SCAPULA COMPLETE RT,4000106,CDM,320,RC,73010RTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SCOLIOSIS STUDY 4-5 VIEWS,4000107,CDM,324,RC,72083TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SHOULDER COMPLETE MIN 2 VIEW RT,4000111,CDM,320,RC,73030TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SKULL <4 VIEWS,4000114,CDM,320,RC,70250TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR STERNUM MIN 2 VIEW,4000120,CDM,324,RC,71120TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR THORACIC SPINE 2 VIEW,4000123,CDM,324,RC,72070TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR THORACIC SPINE 3 VIEW,4000124,CDM,324,RC,72072TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR TIBIA/FIBULA 2 VIEW RT,4000125,CDM,320,RC,73590TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR WRIST COMP MIN 3 VIEW RT,4000135,CDM,320,RC,73110TCRT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR FEMUR 2 VIEW LT(ADD JT IF NEEDED),4000145,CDM,320,RC,73552TCLT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR FOOT COMP MIN 3 VIEWS LT,4000147,CDM,320,RC,73630TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR HAND MIN 3 VIEW LT,4000150,CDM,320,RC,73130TCLT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR HIP UNILATERAL MIN 2 VIEW LT,4000152,CDM,320,RC,73502TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR HUMERUS MIN 2 VIEW LT,4000153,CDM,320,RC,73060TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR KNEE 3 VIEW LT,4000155,CDM,320,RC,73562TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR KNEE COMPLETE 4 OR MORE VIEWS LT,4000156,CDM,320,RC,73564TCLT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR RIBS UNILATERAL 2 VIEW LT,4000158,CDM,324,RC,71100TCLT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SI JOINTS 3 OR MORE VIEWS BIL,4000159,CDM,324,RC,72202TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SCAPULA COMPLETE LT,4000160,CDM,320,RC,73010LTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR SHOULDER COMPLETE MIN 2 VIEW LT,4000162,CDM,320,RC,73030LTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR STERNOCLAVICULAR JOINTS MIN 3 VIEW,4000163,CDM,324,RC,71130TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR T M JOINTS BILATERAL,4000164,CDM,320,RC,70330TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR TIBIA/FIBULA 2 VIEW LT,4000165,CDM,320,RC,73590TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR WRIST COMP MIN 3 VIEW LT,4000168,CDM,320,RC,73110TCLT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
PROCEDURE-LEVEL 1 RADIOLOGY,4310070,CDM,360,RC,,,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,560,
XR RIBS LT UNILATERAL W/1 VIEW CHEST,4000172,CDM,324,RC,71101TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR RIBS RT UNILATERAL W/1 VIEW CHEST,4000173,CDM,324,RC,71101TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR BILATERAL STANDING KNEES AP ONLY,4000176,CDM,320,RC,73565TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR UPPER EXTREMITY INFANT MIN 2 VIEWS RT,4000181,CDM,320,RC,73092RTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR UPPER EXTREMITY INFANT MIN 2 VIEWS LT,4000182,CDM,320,RC,73092LTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR LUMBAR SPINE FLEXION & EXTENTION ONLY,4000201,CDM,320,RC,72120TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR KNEE COMPLETE 4 OR MORE VIEWS RT,4001077,CDM,320,RC,73564RTTC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR CHEST 2 VIEWS*,4001140,CDM,324,RC,71046TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR CHEST WITH LORDOTIC*,4001141,CDM,324,RC,71047TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR CHEST OBLIQUES VIEWS*,4001142,CDM,324,RC,71048TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR ABD 2 VIEW (FLAT AND ERECT)*,4001144,CDM,320,RC,74019TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR TIBIA/FIBULA 2 VIEW,6100709,CDM,320,RC,73590TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR FEMUR 2 VIEW RT,6100716,CDM,320,RC,73552TCRT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR FEMUR 2 VIEW LT(ADD JT IF NEEDED),6100717,CDM,320,RC,73552TCLT,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR CHEST 3VIEWS WITH LORDOTIC*,6100751,CDM,324,RC,71047TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
XR TIBIA/FIBULA 2 VIEW LT,6900154,CDM,320,RC,73590TC,HCPCS,outpatient,,,178,133.5,,142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.63,142.4,
NMR LIPOPROFILE,2800447,CDM,300,RC,83704,HCPCS,outpatient,,,179,134.25,,143.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,94.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,94.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,94.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,98.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,44.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,134.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,34.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.09,143.2,
TYPHOID,6900041,CDM,982,RC,90691,HCPCS,outpatient,,,179,134.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,107.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,107.4,107.4,
BLOOD ALCOHOL MEDICAL,2800115,CDM,301,RC,80320,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.45,144,
COGNITIVE SKILLS DEVELOPMENT,2800175,CDM,420,RC,97532,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,144,
"ANABOLIC STEROIDS, 1 OR 2",2800242,CDM,300,RC,80327,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.34,144,
BB BLOOD-CRYOPRECIPITATE,3000009,CDM,390,RC,P9012,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
PROCRIT 2000 UNITS/ML,3201674,CDM,636,RC,J0885,HCPCS,both,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,180,
XR ESOPHOGRAM SING CONT,4000051,CDM,320,RC,74220TC,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
DEBRIDEMENT OPEN WOUND; TOPICAL APPLICAT,5100548,CDM,420,RC,97598GP,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,144,
DEBRIDEMENT OPEN WOUND; TOPICAL APPLICAT,5100549,CDM,430,RC,97598GO,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,144,
DTAP/IPV/HIB,6000221,CDM,636,RC,90698,HCPCS,both,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,180,
DTAP/IPV/HIB,6100273,CDM,636,RC,90698,HCPCS,both,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,180,
NEW OFFICE VISIT-MINIMAL,6200025,CDM,510,RC,99201,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
OFFICE VISIT-MINIMAL,6200036,CDM,510,RC,99211,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,144,
RURAL HEALTH VISIT,6300127,CDM,521,RC,T1015,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
GROUP THERAPY,6600003,CDM,915,RC,90853,HCPCS,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,205.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,70.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.41,205.08,
PREV MED NP 40-64,6900087,CDM,982,RC,99386,HCPCS,outpatient,,,180,135,,,,,,other,Not separately reimbursable for physician setting,89.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,108,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,111.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,111.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,89.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,89.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,111.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,111.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,89.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,177.76,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,111.1,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.54,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,89.97,177.76,
NM PH CAPTOPRIL,4400030,CDM,250,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
DIFLUCAN 200MG IV PREMIX,3200241,CDM,636,RC,J1450,HCPCS,both,,,180.5,135.38,,144.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.63,180.5,
ROTATEQ VACCINE,6100444,CDM,636,RC,90680,HCPCS,both,,,180.5,135.38,,144.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.63,180.5,
CONCURRENT DRUG INFUSION,1400115,CDM,260,RC,96368,HCPCS,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
DRUG INFUSION EA ADD HOUR,1400118,CDM,260,RC,9636659,HCPCS,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
ER-DRUG INFUSION INTIAL (16 MINS-1HOUR),1400232,CDM,450,RC,9636659,HCPCS,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
THER/PROPH/DIAG IV INF INIT,1400254,CDM,761,RC,90765,HCPCS,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
DRUG INFUSION SEQUENTIAL HOUR,1400256,CDM,260,RC,9636759,HCPCS,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
INJECTION IV (INITIAL IV PUSH),6900221,CDM,982,RC,96374,HCPCS,outpatient,,,182,136.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,109.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,54.21,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,33.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,47.43,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,33.88,109.2,
MUCOMYST 20% 10ML VI,3200575,CDM,636,RC,J7608,HCPCS,both,,,182.5,136.88,,146,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.44,182.5,
ACETADOTE 200MG/ML 30ML VIAL,3202006,CDM,636,RC,J0132,HCPCS,both,,,182.5,136.88,,146,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.44,182.5,
PREMARIN 25MG IV,3200693,CDM,636,RC,J1410,HCPCS,both,,,183,137.25,,146.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,558.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.64,595.96,
ER ARTERIAL PUNCTURE,1400011,CDM,450,RC,36600,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,171.6,
FBR:EAR CANAL,1400081,CDM,450,RC,69200,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.04,171.6,
URETHRAL CATHERTIZATION,1400112,CDM,450,RC,51702,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.04,171.6,
ER INSERTION FOLEY CATHETER,1400113,CDM,450,RC,51702,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.04,171.6,
ER INSERTION NON INDWELLING CATH BLADDER,1400114,CDM,450,RC,51701,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.04,171.6,
INSERT NON INDWELLING BLADDER CATH,1400225,CDM,450,RC,51701,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.04,171.6,
ANDROSTENEDIONE,2800066,CDM,301,RC,82157,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,103.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,103.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,103.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,38.06,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,29.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,43.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.64,147.2,
SUTURE EXT EAR LACERATION,6200448,CDM,360,RC,12011,HCPCS,outpatient,,,184,138,,147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.04,375.41,
CEMENT SIMPLEX P BONE,890240,CDM,278,RC,C1713,HCPCS,both,,,184.8,138.6,,147.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.36,869.4,
NAPROXEN,2800996,CDM,301,RC,G6039,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,148,
PR CT ABDOMEN WITHOUT,4310007,CDM,972,RC,7415026,HCPCS,outpatient,,,185,138.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,111,111,
INT COMP (AGE 18-39),6000269,CDM,521,RC,99385,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,148,
PREV MED AGE 65+,6000278,CDM,521,RC,99397,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,148,
ANNUAL WELLNESS VISIT SUBSEQUENT,6000286,CDM,521,RC,G0439,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,185,
PREVENTIVE MEDICINE VANTAGE,6000287,CDM,521,RC,G0439,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,185,
INT COMP (AGE 18-39),6100370,CDM,521,RC,99385,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,148,
PREV MED AGE 65+,6100379,CDM,521,RC,99397,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,148,
ANNUAL WELLNESS VISIT SUBSEQUENT,6100380,CDM,521,RC,G0439,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,185,
PREVENTIVE MEDICINE VANTAGE,6110439,CDM,521,RC,G0439,HCPCS,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,185,
IND PSYCHOTHERAPY 75-80 MIN,6300092,CDM,972,RC,90837,HCPCS,outpatient,,,185,138.75,,,,,,other,Not separately reimbursable for physician setting,82.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,128.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,128.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,128.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,128.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,82.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,128.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,128.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,204.85,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,128.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,179.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.4,204.85,
CATECHOLAMINES TOTAL URINE,2800143,CDM,301,RC,82382,HCPCS,outpatient,,,185.5,139.13,,148.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,102.03,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,23.4,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.65,148.4,
SCREW 2.7MM NON LOCKING 14MM,890103,CDM,278,RC,C1713,HCPCS,both,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,869.4,
SCREW 2.4 NON-LOCKING 18MM,890199,CDM,278,RC,C1713,HCPCS,both,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,869.4,
H INFLUENZA B ANTIBODY,2800314,CDM,301,RC,86684,HCPCS,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,55.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.92,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,102.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.59,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.76,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.92,148.8,
SELECTIVE DEBRIDEMENT,2800551,CDM,430,RC,97597,HCPCS,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,266.87,
ACUTE ADM/DC SAME DAY,6100329,CDM,982,RC,99234,HCPCS,outpatient,,,186,139.5,,,,,,other,Not separately reimbursable for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,154.74,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,135.39,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,88.3,154.74,
PUNCH BIOPSY EACH ADDL LESION,6100715,CDM,361,RC,11105,HCPCS,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,194.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,194.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,194.41,
REMOVE FOREIGN BODY EAR W/O ANESTHESIA,6200464,CDM,360,RC,69200,HCPCS,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,171.6,
PUNCH BIOPSY EACH ADDL LESION,6200601,CDM,361,RC,11105,HCPCS,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,194.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,194.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,194.41,
INJ ANES AGENT/STEROID ILIOINGUINAL NERV,6200618,CDM,360,RC,64425,HCPCS,outpatient,,,186,139.5,,148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,952.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.85,952.29,
SFMC MAYO FUNGUS ID,2801355,CDM,306,RC,87107,HCPCS,outpatient,,,187,140.25,,149.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,102.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.51,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.16,149.6,
K-WIRE (703818),890097,CDM,278,RC,C1769,HCPCS,both,,,187.2,140.4,,149.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.33,187.2,
XR HIP BILATERAL AND PELVIS 2 VIEWS,6100559,CDM,320,RC,73521TC,HCPCS,outpatient,,,188,141,,150.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.65,150.4,
TESTOSTERONE FREE AND WEAKLY BOUND,2801098,CDM,301,RC,84410,HCPCS,outpatient,,,189,141.75,,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,102.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,103.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,66.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,51.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,51.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,82.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,51.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.64,151.2,
ROTAVIRUS IMMUNIZATION,6900037,CDM,982,RC,90680,HCPCS,outpatient,,,189,141.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,113.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,113.4,113.4,
CHROMOGRANIN A,2800162,CDM,300,RC,86316,HCPCS,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,73.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.4,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,27.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.4,152,
CYSTIC FIBROSIS PROFILE PART 2,2800230,CDM,306,RC,83900,HCPCS,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
CANNABINOID SYNTHETIC,2801010,CDM,301,RC,80307,HCPCS,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
PER COMP (AGE UNDER 1),6900088,CDM,982,RC,99391,HCPCS,outpatient,,,190,142.5,,,,,,other,Not separately reimbursable for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,114,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,65.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,65.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,54.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,104.4,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,65.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.35,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,54.11,114,
SFMC LIPOPROTEIN A,2800091,CDM,300,RC,83698,HCPCS,outpatient,,,191,143.25,,152.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,101.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,101.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,101.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.15,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,105.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,60.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,60.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.31,100,,,fee schedule,100% UHC fee schedule for outpatient setting,46.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,74.09,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,69.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.15,152.8,
BNP(B-TYPE NATURETIC PEPTIDE),2800120,CDM,301,RC,83880,HCPCS,outpatient,,,191,143.25,,152.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,105.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,51.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,51.04,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.26,100,,,fee schedule,100% UHC fee schedule for outpatient setting,39.26,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.63,152.8,
PLASMA VASOPRESSIN (ADH),2800477,CDM,302,RC,84588,HCPCS,outpatient,,,191,143.25,,152.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,105.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.3,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.97,152.8,
CONSULT OV LEVEL IV,6100337,CDM,521,RC,99244,HCPCS,outpatient,,,191,143.25,,152.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,76.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.86,152.8,
SCREW 3.5MM NON-LOCKING 14MM,890062,CDM,278,RC,C1713,HCPCS,both,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,869.4,
SCREW 3.5 NON-LOCKING 18MM BONE,890119,CDM,278,RC,C1713,HCPCS,both,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,869.4,
SCREW 3.5 NON LOCKING 16MM,890180,CDM,278,RC,C1713,HCPCS,both,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,869.4,
SCREW 3.5 NON-LOCKING 20MM,890205,CDM,278,RC,C1713,HCPCS,both,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,869.4,
SCREW 3.5 NON-LOCKING SCREW 26MM,890248,CDM,278,RC,C1713,HCPCS,both,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,869.4,
SCREW 3.5 MM NON-LOCKING 16MM,890258,CDM,278,RC,C1713,HCPCS,both,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,869.4,
SCREW 3.5 MM NON-LOCKING 38MM,890259,CDM,278,RC,C1713,HCPCS,both,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,869.4,
INHIBIN B,2801066,CDM,301,RC,83520,HCPCS,outpatient,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,105.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,153.6,
INHIBIN A ULTRASENSITIVE,2801099,CDM,301,RC,86336,HCPCS,outpatient,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,55.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.79,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,105.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.38,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.79,153.6,
SFMC INHIBIN A & B TUMOR MARKER,2801291,CDM,301,RC,86336,HCPCS,outpatient,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,55.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,55.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.79,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,105.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.59,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.38,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.79,153.6,
APP CAST SHORT ARM ELBOW TO FINGER,6100701,CDM,521,RC,29075,HCPCS,outpatient,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,354.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,354.56,
ANTI-HU,2800079,CDM,302,RC,86255,HCPCS,outpatient,,,193,144.75,,154.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,106.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,154.4,
STRIATIONAL ANTIBODIES,2800715,CDM,302,RC,86255,HCPCS,outpatient,,,193,144.75,,154.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,106.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,154.4,
PENTACEL VACCINE,6000339,CDM,250,RC,90698,HCPCS,outpatient,,,193.5,145.13,,154.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.86,154.8,
DEBRIDEMENT; OPEN WOUND,5100546,CDM,420,RC,97597GP,HCPCS,outpatient,,,194,145.5,,155.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,155.2,
DEBRIDEMENT; OPEN WOUND,5100547,CDM,430,RC,97597GO,HCPCS,outpatient,,,194,145.5,,155.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,155.2,
MYASTHENIA GRAVIS PROFILE III,2800440,CDM,300,RC,83519,HCPCS,outpatient,,,195,146.25,,156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,107.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.33,156,
URINE 24 HR CITRATE,2800625,CDM,301,RC,82507,HCPCS,outpatient,,,195,146.25,,156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,98.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,107.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,36.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,36.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.48,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.9,156,
ACETAMINOPHEN,2800872,CDM,301,RC,G0480,HCPCS,outpatient,,,195,146.25,,156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.21,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,107.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,183.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.21,183.08,
SALICYLATE,2800873,CDM,301,RC,G0480,HCPCS,outpatient,,,195,146.25,,156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.21,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,107.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,183.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.21,183.08,
NW PT HOME VISIT LEVEL 4,6100479,CDM,522,RC,99344,HCPCS,outpatient,,,195,146.25,,156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.47,156,
BIOPSY MUSCLE PERCUTANEOUS NEEDLE,6200064,CDM,360,RC,20206,HCPCS,outpatient,,,195,146.25,,156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.47,2216.25,
MARKER WIRE FORTE GUIDEWIRE,99999901,CDM,278,RC,C1769,HCPCS,both,,,195.88,146.91,,156.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.82,195.88,
CHROMOSOME ANALYSIS ADDTL HI RESOLUTION,2800165,CDM,311,RC,88289,HCPCS,outpatient,,,196,147,,156.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,146.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.21,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,107.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,44.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,34.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,55.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,51.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.21,156.8,
INT I/P CONSULT IV,6100342,CDM,521,RC,99254,HCPCS,outpatient,,,196,147,,156.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.87,156.8,
"PSYCHOTHERAPY, 30 MIN W/PATIENT",6690832,CDM,914,RC,90832,HCPCS,outpatient,,,196,147,,156.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,78.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.87,215.33,
SUBOXONE BLOOD,2800583,CDM,300,RC,80150,HCPCS,outpatient,,,197,147.75,,157.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,108.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,19.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.54,157.6,
=>PT/OT/ST ORDER<=,5100000,CDM,430,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,70,100,,,other,Not separately reimbursable for outpatient setting,70,100,,,other,Not separately reimbursable for outpatient setting,70,100,,,other,Not separately reimbursable for outpatient setting,70,100,,,other,Not separately reimbursable for outpatient setting,70,100,,,other,Not separately reimbursable for outpatient setting,70,100,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,70,70,
FHC-PREV MED NP 65+,6900187,CDM,982,RC,99387,HCPCS,outpatient,,,197,147.75,,,,,,other,Not separately reimbursable for physician setting,98.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.8,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,118.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.8,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,119.8,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,119.8,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,98.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,98.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,119.8,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,119.8,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,98.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,191.68,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,119.8,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,167.72,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,98.57,191.68,
SCREW 2.7 NON-LOCKING 16MM,890286,CDM,278,RC,C1713,HCPCS,both,,,197.18,147.89,,157.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.35,869.4,
OUTPATIENT-ER VISIT WITH PHYSICIAN,1400243,CDM,761,RC,99212,HCPCS,outpatient,,,198,148.5,,158.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.68,158.4,
CALCITONIN LEVEL,2800130,CDM,301,RC,84145,HCPCS,outpatient,,,198,148.5,,158.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,108.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.61,158.4,
CHLAMYDIA BY NAA,2800156,CDM,306,RC,87491,HCPCS,outpatient,,,198,148.5,,158.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,108.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,158.4,
PLASMODIUM SPECIES DNA (MALARIA),2800479,CDM,300,RC,87798,HCPCS,outpatient,,,198,148.5,,158.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,108.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,158.4,
SFMC ANTI MULLERIAN HORMONE,2801038,CDM,301,RC,83520,HCPCS,outpatient,,,198,148.5,,158.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,108.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,158.4,
SFMC TRICHOMONAS BY NAA,2801295,CDM,306,RC,87661,HCPCS,outpatient,,,198,148.5,,158.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,102.1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.1,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,108.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,158.4,
NURSING ASSISTANCE W/MOD 25,1400242,CDM,450,RC,9921125,HCPCS,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.08,159.2,
WOUND CLINIC OV EST MINIMAL,1499211,CDM,761,RC,99211,HCPCS,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.08,159.2,
VIP(VASOACTIVE INT. PEPTIDE),2800644,CDM,301,RC,84586,HCPCS,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,124.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,124.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,124.77,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,109.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.93,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.99,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.66,159.2,
ZINC WHOLE BLOOD,2801082,CDM,300,RC,84630,HCPCS,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.2,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.69,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,109.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.69,159.2,
EMG 3 EXT,5600012,CDM,922,RC,95863,HCPCS,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.08,214.92,
NEW OFFICE VISIT-BRIEF,6200021,CDM,510,RC,99202,HCPCS,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,159.2,
OFFICE VISIT- LVL II,6200032,CDM,510,RC,99212,HCPCS,outpatient,,,199,149.25,,159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,159.2,
NEW LEVEL 1 OV,6900072,CDM,982,RC,99201,HCPCS,outpatient,,,199,149.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,119.4,119.4,
NEW LEVL 2 OV,6900073,CDM,982,RC,99202,HCPCS,outpatient,,,199,149.25,,,,,,other,Not separately reimbursable for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,46.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,46.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,74.85,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,46.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.49,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,42.77,119.4,
EST LEVEL 1 OV,6900077,CDM,982,RC,99211,HCPCS,outpatient,,,199,149.25,,,,,,other,Not separately reimbursable for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,12.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,8.56,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.98,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.56,119.4,
EST LEVEL 2 OV,6900078,CDM,982,RC,99212,HCPCS,outpatient,,,199,149.25,,,,,,other,Not separately reimbursable for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,34.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,34.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,34.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,34.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,34.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,34.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,55.44,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,34.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.51,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,24.83,119.4,
GASTROSTOMY REMOVAL,400084,CDM,490,RC,99211,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33,160,
PR FLUORO SPINE INJECTION/SURGICAL,401003,CDM,972,RC,77003,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,69.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,69.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,69.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,110.8,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,69.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.95,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,69.25,120,
C-ANCA,2800136,CDM,302,RC,86255,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,160,
CD4 COUNT,2800147,CDM,300,RC,86361,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,71.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.39,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,34.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,34.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.39,160,
DRUG SCREEN - SERUM,2800248,CDM,300,RC,80307,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
TACROLIMUS LEVEL,2800592,CDM,301,RC,80197,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.86,160,
ENTEROVIRUS REAL TIME PCR,2800973,CDM,306,RC,87498,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,104.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,104.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,160,
SFMC INTRINSIC FACTOR BLOCKING ANTIBODY,2800990,CDM,302,RC,86343,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.23,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.2,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.46,100,,,fee schedule,100% UHC fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.23,160,
DRUG SCREEN - WHOLE BLOOD,2801041,CDM,300,RC,80307,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,169.05,
SFMC TACROLIMUS LEVEL,2801229,CDM,301,RC,80197,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.86,160,
ROCEPHIN 1GM/10mL VIAL INJ,3200759,CDM,636,RC,J0696,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
OPTIRAY 300 500mL,3201137,CDM,636,RC,Q9967,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
ISOVUE-300  500ML,3207831,CDM,636,RC,Q9967,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
PR XR SHOULDER ARTHROGRAM,4010110,CDM,972,RC,7304026,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR NM PARATHYROID IM*,4010215,CDM,972,RC,7807026,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
MRI MULTIHANCE 20ML,4200031,CDM,636,RC,A9576,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
PR CT LOWER EXT WITHOUT RT,4310023,CDM,972,RC,7370026RT,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT L-SPINE WITHOUT,4310027,CDM,972,RC,7213126,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT SINUSES WITHOUT,4310039,CDM,972,RC,7048626,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT T-SPINE WITH,4310041,CDM,972,RC,7212926,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT T-SPINE WITHOUT,4310042,CDM,972,RC,7212826,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT UPPER EXT WITHOUT RT,4310045,CDM,972,RC,7320026RT,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT LOWER EXT WITHOUT LT,4310062,CDM,972,RC,7370026LT,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT LOWER EXTREMITY LT,4310063,CDM,972,RC,73706LT26,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT UPPER EXT WITH CONTRAST LT,4310065,CDM,972,RC,7320126LT,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR CT UPPER EXT WITHOUT LT,4310066,CDM,972,RC,7320026LT,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR NM BONE 3 PHASE,4410004,CDM,972,RC,7831526,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR NM BONE SPECT,4410006,CDM,972,RC,7832026,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR NM MUGA BLOOD POOL IMAGING,4410022,CDM,972,RC,7847226,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
DO NOT USE,4410024,CDM,972,RC,7807126,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR NM RENAL FLOW W/PHARMACOLGIC INT,4410051,CDM,972,RC,7870826,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
PR NM SENTINEL NODE INJECTION/IMAGING,4410054,CDM,972,RC,7819526,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
INC & DRAIN OF ABSCESS,6000101,CDM,521,RC,10060,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,375.41,
SHAVE LESION 0.6CM-1.0CM,6000113,CDM,521,RC,11301,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,266.88,
SHAVING LESION OVER 2CM,6000114,CDM,521,RC,11303,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,551.37,
SHAVING 0.6CM TO 1.0 CM,6000116,CDM,521,RC,11306,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,266.88,
EXCISION OF LESION 2 CM,6000128,CDM,521,RC,11602,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,786.48,
REPAIR LACRATION < 2 CM,6000136,CDM,521,RC,12001,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,375.41,
CYTOPATH  C/V INTERPRET SCC,6000195,CDM,521,RC,88141,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,160,
"VARICELLA VACCINE, LIVE",6000229,CDM,636,RC,90716,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
EST LEVEL 5 OV,6000264,CDM,521,RC,99215,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,224.87,
ADACEL INJ (TDAP) FOR 7 YEARS AND UP,6000319,CDM,636,RC,90715,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
INC & DRAIN OF ABSCESS,6100043,CDM,521,RC,10060,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,375.41,
SHAVING LESION OVER 2CM,6100055,CDM,521,RC,11303,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,551.37,
SHAVE LESION 0.6CM-1.0CM,6100057,CDM,521,RC,11301,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,266.88,
EXCISION OF LESION 2 CM,6100064,CDM,521,RC,11602,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,786.48,
REPAIR LACRATION < 2 CM,6100070,CDM,521,RC,12001,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,375.41,
INSERT ENDOTRACH TUBE,6100091,CDM,521,RC,31500,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,466.07,
CL-ADACEL INJ (TDAP),6100108,CDM,636,RC,90715,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
BIOPSY OF THE CERVIX,6100131,CDM,521,RC,57500,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,788.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,788.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,788.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1039.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,974.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,1039.68,
CYTOPATH  C/V INTERPRET,6100236,CDM,521,RC,88141,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,160,
PHY CARE PLAN OVERSIGHT,6100248,CDM,969,RC,G0181,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,159.5,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.57,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,159.5,
VARICELLA VACCINE,6100282,CDM,636,RC,90716,HCPCS,both,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,200,
EST LEVEL 5 OV,6100396,CDM,521,RC,99215,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,224.87,
LONG ARM CAST(SHOULDER TO HAND),6100553,CDM,521,RC,29065,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,354.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,354.56,
SHAVING 0.6CM TO 1.0 CM,6111306,CDM,521,RC,11306,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,266.88,
BIOPSY OF VULVA OR PERINEUM,6200068,CDM,360,RC,56605,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1039.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,974.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,1039.68,
GASTRIC INTUB/ASP/THERAPEUTIC/LAVAGE,6200175,CDM,360,RC,43753,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,147.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,147.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,413.91,
DEB SUBQ TISSUE ADD-ON,6200414,CDM,360,RC,11045,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,160,
EXCISION OF NAIL PARTIAL OR COMP,6300076,CDM,521,RC,11750,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,786.48,
INC & DRAIN OF ABSCESS,6300085,CDM,521,RC,10060,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,375.41,
REMOVAL SKIN TAGS UP TO 15,6300118,CDM,521,RC,11200,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,266.88,
SHAVING LESION OVER 2CM,6300129,CDM,521,RC,11303,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,551.37,
ZOSTAVAX .65 ML,6300157,CDM,972,RC,97036,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,32.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,32.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,32.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,32.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,32.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,32.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,51.41,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,32.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,44.98,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,32.13,120,
PSYCHOTHERAPY FOR CRISIS; FIRST 30 MINS,6300183,CDM,972,RC,90839,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,114.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,123.59,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,123.59,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,123.59,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,123.59,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,114.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,114.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,123.59,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,123.59,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,114.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,197.74,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,123.59,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,173.03,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,114.54,197.74,
PSYCHOTHERAPY 60 MIN,6300186,CDM,972,RC,90838,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,75.84,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.93,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.93,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.93,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.93,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,75.84,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,75.84,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.93,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,102.93,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75.84,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,164.69,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,102.93,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,144.1,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,75.84,164.69,
IND/THERAPY 20-30 MIN,6600005,CDM,915,RC,90804,HCPCS,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
OBSERVATION-INITIAL CARE/DAY 50 MINS,7000012,CDM,982,RC,99219,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
SWING BED SUBSEQUENT-35 MINS,7000031,CDM,982,RC,99310,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,82.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,147.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,147.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,147.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,147.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,82.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,147.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,147.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.17,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,236.74,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,147.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,207.14,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.17,236.74,
PR KNEE ARTHROGRAPHY,40100010,CDM,972,RC,7358026,HCPCS,outpatient,,,200,150,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,120,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,120,120,
LOVENOX 60MG INJ,3200515,CDM,636,RC,J1650,HCPCS,both,,,200.5,150.38,,160.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.68,200.5,
CIPROFLOXACIN SERUM OR PLASMA,2801434,CDM,301,RC,80299,HCPCS,outpatient,,,201,150.75,,160.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,110.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,160.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,160.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,160.8,
SFMC MAYO YEAST SUSCEPTIBILITY,2801356,CDM,306,RC,87186,HCPCS,outpatient,,,202,151.5,,161.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,111.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,151.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,161.6,
VORICONAZOLE LEVEL,2801427,CDM,301,RC,80285,HCPCS,outpatient,,,202.5,151.88,,162,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.82,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.55,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,111.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,35.24,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,151.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,27.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,43.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.55,162,
BONE MARROW ASPIRATION ONLY,6200069,CDM,360,RC,38220,HCPCS,outpatient,,,203,152.25,,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,81.69,2216.25,
PER COMP (AGE 01-4),6900089,CDM,982,RC,99392,HCPCS,outpatient,,,203,152.25,,,,,,other,Not separately reimbursable for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,121.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.07,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60.5,121.8,
PER COMP (AGE 05-11),6900090,CDM,982,RC,99393,HCPCS,outpatient,,,203,152.25,,,,,,other,Not separately reimbursable for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,121.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.07,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,71.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60.25,121.8,
TRI-LUMEN CVC KIT 7FR 16CM,100840,CDM,272,RC,C1751,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,163.2,
ER APPLICATION FINGER SPLINT DYNAMIC,1400009,CDM,450,RC,29131,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,163.2,
ER APPLICATION SHORT ARM SPLINT DYNAMIC,1400010,CDM,450,RC,29126,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,171.6,
ER STRAPPING ELBOW OR WRIST,1400199,CDM,450,RC,29260,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,163.2,
ER STRAPPING HAND OR FINGER,1400200,CDM,450,RC,29280,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,163.2,
ER STRAPPING TOES,1400205,CDM,450,RC,29550,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,163.2,
RABIES VACC,6000214,CDM,636,RC,90675,HCPCS,both,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,525.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,492.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,525.66,
RABIES VACC,6100287,CDM,636,RC,90675,HCPCS,both,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,525.66,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,492.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,525.66,
EMERGENCY ROOM LEVEL 3,6200001,CDM,450,RC,99283,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,362.12,
RABIES VACC,6300021,CDM,972,RC,90675,HCPCS,outpatient,,,204,153,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,122.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,525.68,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,459.97,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,122.4,525.68,
IND/THERAPY 45-50MIN,6600007,CDM,914,RC,90806,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,163.2,
PSYCHIATRIC DIAG INTERVIEW EXAMINATION,6600019,CDM,914,RC,90801,HCPCS,outpatient,,,204,153,,163.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,82.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.09,163.2,
DTAP/IPV/HIB,6900043,CDM,982,RC,90698,HCPCS,outpatient,,,204,153,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,122.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,122.4,122.4,
DEBRIDEMENT FULL THICKNESS,6200322,CDM,361,RC,11041,HCPCS,outpatient,,,205,153.75,,164,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.49,164,
ADH ANTIDIURATIC HRM,2800029,CDM,301,RC,84588,HCPCS,outpatient,,,206,154.5,,164.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,113.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.3,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.97,164.8,
CATECHOLAMINE PLASMA,2800142,CDM,301,RC,82384,HCPCS,outpatient,,,206,154.5,,164.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,113.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.62,164.8,
VON WILLEBRAND FACTOR,2800658,CDM,305,RC,85245,HCPCS,outpatient,,,206,154.5,,164.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,11.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,113.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,29.82,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,36.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.47,164.8,
SFMC CATECHOLAMINE PLASMA,2801251,CDM,301,RC,82384,HCPCS,outpatient,,,206,154.5,,164.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,89.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.62,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,113.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,32.83,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.25,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.25,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,25.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.62,164.8,
SFMC ADH ANTIDIURETIC HRM,2801270,CDM,301,RC,84588,HCPCS,outpatient,,,206,154.5,,164.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.97,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,113.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,33.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.3,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.97,164.8,
EXTERNAL EAR BIOPSY,6200169,CDM,360,RC,69105,HCPCS,outpatient,,,206,154.5,,164.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,113.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.89,3047.65,
SFMC CPT 87118 CHG AFB CULTURE ID,2801372,CDM,306,RC,87150,HCPCS,outpatient,,,207,155.25,,165.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,88.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,113.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,165.6,
SFMC H PYLORI STOOL ANTIGEN,2801237,CDM,300,RC,87338,HCPCS,outpatient,,,208,156,,166.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,114.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,166.4,
DIAGNOSTIC SIGMOIDOSCOPY,6200337,CDM,510,RC,45330,HCPCS,outpatient,,,209,156.75,,167.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,84.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,167.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.1,1228.22,
VITAMIN B2,2800648,CDM,300,RC,84252,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,71.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,71.47,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,10.11,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,26.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,26.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.24,100,,,fee schedule,100% UHC fee schedule for outpatient setting,20.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,32.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.11,168,
VITAMIN K1,2800653,CDM,300,RC,84597,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.86,168,
TRYPTASE,2801115,CDM,302,RC,83520,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,168,
SFMC VITAMIN K1,2801286,CDM,300,RC,84597,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.72,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.86,168,
PROTHROMBIN DNA ANALYSIS,2801327,CDM,305,RC,81240,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,140.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,140.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.84,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,85.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,85.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.69,100,,,fee schedule,100% UHC fee schedule for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.84,168,
SFMC CPT 83520 CHG ONLY,2801368,CDM,300,RC,83520,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,168,
PLACE BREAST CLIP PERCUT,6200452,CDM,360,RC,19295,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
BX SKIN SINGLE LESION,6200632,CDM,360,RC,11102,HCPCS,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,562.17,
SHAVE BIOPSY; SINGLE LESION,6900253,CDM,982,RC,11102,HCPCS,outpatient,,,210,157.5,,,,,,other,Not separately reimbursable for physician setting,69.91,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,126,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,69.91,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,69.91,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,36.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69.91,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,58.64,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,36.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,51.31,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36.65,126,
PR MRI THOR/SPINE W/O CONTRAST,4210044,CDM,972,RC,7214626,HCPCS,outpatient,,,211,158.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,126.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,126.6,126.6,
SCREW 6.5MM LOW PROFILE HEX,890169,CDM,278,RC,C1713,HCPCS,both,,,212,159,,169.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,85.31,869.4,
SCREW 6.5 LOW PROFILE HEX 25MM,890170,CDM,278,RC,C1713,HCPCS,both,,,212,159,,169.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,85.31,869.4,
SCREW 6.5MM LOW PROFILE HEX 35MM,890279,CDM,278,RC,C1713,HCPCS,both,,,212,159,,169.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,85.31,869.4,
SCREW 6.5MM LOW PROFILE HEX 20MM,890280,CDM,278,RC,C1713,HCPCS,both,,,212,159,,169.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,85.31,869.4,
I&D EVAC SUBUNGUAL HEMATOMA,1400074,CDM,450,RC,11740,HCPCS,outpatient,,,212,159,,169.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,142.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,142.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,85.31,171.6,
B CELLS - TOTAL COUNT,2800103,CDM,301,RC,86355,HCPCS,outpatient,,,212,159,,169.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,112.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,112.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,112.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,116.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.86,169.6,
T CELLS - TOTAL COUNT,2800586,CDM,301,RC,86359,HCPCS,outpatient,,,212.32,159.24,,169.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,133.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,133.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,133.19,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,116.78,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,49.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,169.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.73,100,,,fee schedule,100% UHC fee schedule for outpatient setting,37.73,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.36,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,169.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.86,169.86,
HBV DNA BY PCR,2801394,CDM,306,RC,87517,HCPCS,outpatient,,,213,159.75,,170.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,117.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,170.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,170.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.42,170.4,
INCISION & DRAIN ABSCSS SINGLE PRO FEE,7000041,CDM,982,RC,10060,HCPCS,outpatient,,,213,159.75,,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,159.07,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.19,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,65.58,159.07,
XR FLUORO CVA PLACEMENT,4000057,CDM,320,RC,77001TC,HCPCS,outpatient,,,214,160.5,,171.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.7,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.11,171.2,
LEVAQUIN 750MG 150ML PREMIX,3200462,CDM,636,RC,J1956,HCPCS,both,,,215,161.25,,172,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,118.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.52,215,
PR CT C-SPINE WITHOUT,4310015,CDM,972,RC,7212526,HCPCS,outpatient,,,215,161.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,129,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,129,129,
MENACTRA VACCINE,6000233,CDM,636,RC,90734,HCPCS,both,,,215,161.25,,172,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,118.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.52,215,
MENACTRA VACCINE,6100290,CDM,636,RC,90734,HCPCS,both,,,215,161.25,,172,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,118.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.52,215,
"BLADDER IRRIGATION, SIMPLE LAVAGE",6100474,CDM,521,RC,51700,HCPCS,outpatient,,,215,161.25,,172,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.52,317.56,
O2 PER HR,5200004,CDM,271,RC,,,outpatient,,,480,360,,384,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,193.15,384,
SHAVE SKIN LESION 0.6 TO 1.0 CM,6200466,CDM,360,RC,11311,HCPCS,outpatient,,,215,161.25,,172,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,161.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.52,266.87,
SPIROMETRY,5200045,CDM,460,RC,94010,HCPCS,outpatient,,,216,162,,172.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,118.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.92,214.93,
AEROSOL EFF BAG-DISP,5200008,CDM,270,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
OBS ADMIT LEVEL III,6100321,CDM,982,RC,99220,HCPCS,outpatient,,,216,162,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,129.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,129.6,129.6,
AC ADM LEVEL III,6100324,CDM,987,RC,99223,HCPCS,outpatient,,,216,162,,,,,,other,Not separately reimbursable for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,129.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,270.96,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,237.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,125.54,270.96,
HEPATITIS C FIBROSURE,2800701,CDM,302,RC,81596,HCPCS,outpatient,,,216.57,162.43,,173.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,153.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,153.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,153.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,119.11,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,93.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,93.85,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,173.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,72.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,72.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,72.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,115.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,173.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.09,173.26,
ACTH,2800027,CDM,301,RC,82024,HCPCS,outpatient,,,217,162.75,,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,119.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.93,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.3,173.6,
ACTH,2800028,CDM,301,RC,82024,HCPCS,outpatient,,,217,162.75,,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,119.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.93,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.3,173.6,
AMBU BAG-DISP,5200014,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
VITAMIN D 1.25 OH,2800651,CDM,301,RC,82652,HCPCS,outpatient,,,217,162.75,,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,135.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,135.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,135.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,119.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,50.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.05,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,38.5,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.25,173.6,
SFMC ACTH,2801185,CDM,301,RC,82024,HCPCS,outpatient,,,217,162.75,,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,136.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,119.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,50.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.62,100,,,fee schedule,100% UHC fee schedule for outpatient setting,38.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.93,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.3,173.6,
DESTROY SKIN LESIONS-LEVEL 1,6200334,CDM,510,RC,17110,HCPCS,outpatient,,,217,162.75,,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,119.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,87.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.32,266.88,
BALLARD CATHETER,5200019,CDM,272,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
US FETAL AGE,4100013,CDM,402,RC,76815TC,HCPCS,outpatient,,,218,163.5,,174.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.72,174.4,
US FETAL AGE (FOLLOW-UP/REPEAT),4100014,CDM,402,RC,76816TC,HCPCS,outpatient,,,218,163.5,,174.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.72,174.4,
MENINGOCOCCAL VACCINE,6000232,CDM,636,RC,90733,HCPCS,both,,,218,163.5,,174.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.72,218,
CO2 DETECTOR DISP,5200023,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
CL-MENINGOCOCCAL VACCINE,6100289,CDM,636,RC,90733,HCPCS,both,,,218,163.5,,174.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.72,218,
US BILATERAL OR UNILATERAL BREAST,40000170,CDM,402,RC,76642TC,HCPCS,outpatient,,,218,163.5,,174.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.72,174.4,
ASSAY AMINOLEVULINIC ACIT 24HR,2800102,CDM,305,RC,82135,HCPCS,outpatient,,,219,164.25,,175.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.22,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,120.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,21.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,21.39,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.67,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.22,175.2,
BURN,6100410,CDM,521,RC,16000,HCPCS,outpatient,,,219,164.25,,175.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,109.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.13,266.88,
ANOSCOPY AND DILATION,6200059,CDM,360,RC,46604,HCPCS,outpatient,,,219,164.25,,175.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1510.22,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1510.22,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1510.22,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.13,1600.47,
CROUPETTE CANOPY OXYGEN,5200031,CDM,271,RC,,,outpatient,,,41.5,31.13,,33.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.7,33.2,
REVERSE T3,2800538,CDM,302,RC,84482,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,121,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.21,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.32,176,
ENDOTRACH TUBE,5200034,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
ENDOTUBE HOLDER,5200035,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
SFMC REVERSE T3,2801227,CDM,302,RC,84482,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.88,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,121,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.49,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.32,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.21,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.32,176,
FACE TENT - SUPPLY,5200039,CDM,270,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
FIT RITE MASK,5200040,CDM,271,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
FACTOR V LEIDEN,2801276,CDM,305,RC,81241,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,160.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.68,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,121,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,117.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.68,176,
HEART NEBULIZER,5200042,CDM,271,RC,,,outpatient,,,77.5,58.13,,62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.19,62,
HEAT & MOIST EXCHANG,5200043,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
XR FLUORO CVA PLACEMENT,4000190,CDM,320,RC,77001TC,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,176,
PR CT PELVIS WITHOUT,4310036,CDM,972,RC,7219226,HCPCS,outpatient,,,220,165,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,132,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,132,132,
HUMIDIFIER 02-DISP,5200046,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NM PH ADENOSINE 30 MG  PER 1MG,4400027,CDM,636,RC,J0153,HCPCS,both,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,220,
PREV MED NP 40-64,6000270,CDM,521,RC,99386,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,176,
PREV MED NP 40-64,6100371,CDM,521,RC,99386,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,176,
IPPB CIRCUIT DISP,5200050,CDM,270,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
EST PT HOME VISIT LEVEL 5,6100484,CDM,522,RC,99350,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,176,
VENT MGMT INPATIENT SUBQ DAY,6200316,CDM,360,RC,94003,HCPCS,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,121,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,822.79,
NASAL AIRWAY,5200053,CDM,272,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NEBULIZ LG RES-DISP,5200054,CDM,271,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
NEBULIZER II,5200055,CDM,271,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
NON-REBREATHING MASK,5200056,CDM,270,RC,,,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,11.6,
O2 - ER/RR/OB/LPD,5200057,CDM,270,RC,,,outpatient,,,36.5,27.38,,29.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.69,29.2,
ORAL AIRWAY,5200058,CDM,271,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
PSYCHIATRIC DIAGNOSTIC EVALUATION,6300189,CDM,972,RC,90791,HCPCS,outpatient,,,220,165,,,,,,other,Not separately reimbursable for physician setting,102.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,149.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,132,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,149.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,149.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,149.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,238.62,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,149.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,208.8,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,102.85,238.62,
HOSPICE CARE SUPERVISION (30 MIN),6900223,CDM,982,RC,G0182,HCPCS,outpatient,,,220,165,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100.29,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,132,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100.29,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.29,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.29,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100.29,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,100.29,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,160.46,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,100.29,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,140.41,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,100.29,160.46,
PEAK FLOW METER,5200061,CDM,271,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
HOME HEALTH SUPERVISION (30 MIN),6900224,CDM,982,RC,G0181,HCPCS,outpatient,,,220,165,,,,,,other,Not separately reimbursable for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,132,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.43,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,159.5,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,99.69,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.57,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.69,159.5,
PNEUMOCOCCAL (PNEUMOVAX 23) AGES 2 >,6000231,CDM,636,RC,90732,HCPCS,both,,,221,165.75,,176.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.93,221,
DO NOT USE,5200064,CDM,410,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PNEUMOCOCCAL (PNEUMOVAX 23),6100288,CDM,636,RC,90732,HCPCS,both,,,221,165.75,,176.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.93,221,
ROOM HUMIDIFIER,5200067,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
INT COMP (AGE 01 -4),6900083,CDM,982,RC,99382,HCPCS,outpatient,,,221,165.75,,,,,,other,Not separately reimbursable for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,76.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,132.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,76.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,76.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,76.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,76.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,76.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,122.4,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,76.5,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,107.1,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,70.76,132.6,
SAT PROBE-DISP,5200069,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
PREMARIN PER 25 MG,6100017,CDM,636,RC,J1410,HCPCS,both,,,222,166.5,,177.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,558.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,89.33,595.96,
PNEUMOVAX  23 INJ,3200675,CDM,636,RC,90732,HCPCS,both,,,222.75,167.06,,178.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,89.63,222.75,
SMALL BOWEL ENDOSCOPY,6200292,CDM,360,RC,44380,HCPCS,outpatient,,,223,167.25,,178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,122.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,89.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,167.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,89.74,1717.12,
PER COMP (AGE 12-17),6900091,CDM,982,RC,99394,HCPCS,outpatient,,,223,167.25,,,,,,other,Not separately reimbursable for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,133.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,129.71,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,113.5,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,66.4,133.8,
METHYLENETETRAHYDROFOLATE REDUCTASE,2801021,CDM,305,RC,81291,HCPCS,outpatient,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,139.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,139.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,123.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,84.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.94,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.34,100,,,fee schedule,100% UHC fee schedule for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.01,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.67,180,
ROCEPHIN 2GM INJ,3200761,CDM,636,RC,J0696,HCPCS,both,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.54,225,
TRACH MASK,5200076,CDM,272,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
TUBING CONNECTOR SHER272013-10768,5200077,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VENTURI MASK,5200078,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
PR MRI ABDOMEN W/O CONTRAST,4210009,CDM,972,RC,7418126,HCPCS,outpatient,,,225,168.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,135,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,135,135,
PR MRI CER/SPINE W/O CONTRAST,4210018,CDM,972,RC,7214126,HCPCS,outpatient,,,225,168.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,135,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,135,135,
PR MRI TEMPOROMANDIBULAR JTS,4210042,CDM,972,RC,7033626,HCPCS,outpatient,,,225,168.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,135,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,135,135,
WYE ADAPTER,5200082,CDM,271,RC,,,outpatient,,,12.5,9.38,,10,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.03,10,
PR Bx Abd/Ret Pqx Needle,4210083,CDM,972,RC,49180,HCPCS,outpatient,,,225,168.75,,,,,,other,Not separately reimbursable for physician setting,107.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,135,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,107.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,107.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,107.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,130.61,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,81.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,114.28,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.63,135,
PR CT SINUSES WITH,4310037,CDM,972,RC,7048726,HCPCS,outpatient,,,225,168.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,135,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,135,135,
NEW PT LEVEL 5 OV,6000256,CDM,521,RC,99205,HCPCS,outpatient,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.54,224.87,
NEW PT LEVEL 5 OV,6100389,CDM,521,RC,99205,HCPCS,outpatient,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.54,224.87,
BARTONELLA ANTIBODY PROFILE,2800108,CDM,300,RC,86611,HCPCS,outpatient,,,226,169.5,,180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,35.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.09,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,124.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,13.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.18,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.27,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.09,180.8,
C1 ESTERASE INHIBITOR ANTIGEN,2800125,CDM,302,RC,86160,HCPCS,outpatient,,,227,170.25,,181.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,124.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,181.6,
CD4 & CD8 COUNT,2800146,CDM,301,RC,86360,HCPCS,outpatient,,,227,170.25,,181.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,124.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,75.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.49,181.6,
C1 ESTERASE INHIBITOR FUNCTIONAL,2800992,CDM,302,RC,86161,HCPCS,outpatient,,,227,170.25,,181.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,124.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.6,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6,181.6,
SFMC CD4 & CD8 COUNT,2801202,CDM,301,RC,86360,HCPCS,outpatient,,,227,170.25,,181.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.16,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.49,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,124.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.07,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,46.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,75.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,70.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.49,181.6,
MODIFIED RADICAL MASTECTOMY,400099,CDM,360,RC,19307,HCPCS,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7579.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7579.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7579.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8783.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,8783.64,
TX-IV THERAPY UP TO 1 HR,1600010,CDM,260,RC,90760,HCPCS,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,182.4,
XR VCUG,4000131,CDM,320,RC,74455TC,HCPCS,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,182.4,
XR VOIDING CYSTOGRAM,4000198,CDM,320,RC,74455TC,HCPCS,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,182.4,
PNEUMOVAX 23,6900053,CDM,982,RC,90732,HCPCS,outpatient,,,228,171,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,133.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,136.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,133.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,133.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,133.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,133.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,133.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,213.55,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,133.47,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,186.86,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,133.47,213.55,
PER COMP (AGE 18-39),6900092,CDM,982,RC,99395,HCPCS,outpatient,,,228,171,,,,,,other,Not separately reimbursable for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,136.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,134,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,83.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,117.25,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,66.65,136.8,
ALDOSTERONE SERUM OR PLASMA,2800036,CDM,301,RC,82088,HCPCS,outpatient,,,229,171.75,,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,125.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.37,183.2,
SFMC ALDOSTERONE SERUM,2801232,CDM,301,RC,82088,HCPCS,outpatient,,,229,171.75,,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,125.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.37,183.2,
NEW OFFICE VISIT-LIMITED,6200024,CDM,510,RC,99203,HCPCS,outpatient,,,229,171.75,,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38,183.2,
OFFICE VISIT- LVL III,6200035,CDM,510,RC,99213,HCPCS,outpatient,,,229,171.75,,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38,183.2,
NEW LEVEL 3 OV,6900074,CDM,982,RC,99203,HCPCS,outpatient,,,229,171.75,,,,,,other,Not separately reimbursable for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,80.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,137.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,80.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,80.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,80.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,80.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,80.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,129.58,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,80.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,113.39,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.18,137.4,
EST LEVEL 3 OV,6900079,CDM,982,RC,99213,HCPCS,outpatient,,,229,171.75,,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,137.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.8,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,64.25,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,89.95,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,41.53,137.4,
PACEMAKER CHECK,5500008,CDM,410,RC,,,outpatient,,,124,93,,99.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.9,99.2,
SFMC UREAPLASMA,2801338,CDM,306,RC,87798,HCPCS,outpatient,,,230,172.5,,184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,126.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,184,
SFMC MYCOPLASMA URINE,2801348,CDM,306,RC,87798,HCPCS,outpatient,,,230,172.5,,184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,126.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,184,
SFMC MAYO AFB SLO GRO SUSCEPTIBILITY,2801357,CDM,306,RC,87186,HCPCS,outpatient,,,230,172.5,,184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,126.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,184,
PR CT GUIDED NEEDLE PLACEMENT,4310020,CDM,972,RC,7701226,HCPCS,outpatient,,,230,172.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,138,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,138,138,
ST STAGGERED SPONDAIC WORD TEST,5100629,CDM,440,RC,92572GN,HCPCS,outpatient,,,230,172.5,,184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,184,
STRESS EKG HOOK-UP,5500014,CDM,410,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
REMOVE DRUG IMPLANT DEVICE,6210568,CDM,982,RC,11982,HCPCS,outpatient,,,230,172.5,,,,,,other,Not separately reimbursable for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,138,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,117.12,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.48,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,138,
PRO FEE FAM PSYCHOTHERAPY WITH PATIENT,6600011,CDM,960,RC,90847,HCPCS,outpatient,,,230,172.5,,,,,,other,Not separately reimbursable for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,138,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75.36,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,156.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,98.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,137.35,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,75.36,156.98,
PRO FEE FAM PSYCHOTHERAPY WO PATIENT,6600012,CDM,960,RC,90846,HCPCS,outpatient,,,230,172.5,,,,,,other,Not separately reimbursable for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,138,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,60.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,150.61,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,94.13,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,131.78,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,60.76,150.61,
INT COMP (AGE 05-11),6900084,CDM,982,RC,99383,HCPCS,outpatient,,,230,172.5,,,,,,other,Not separately reimbursable for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,138,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,129.71,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,81.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,113.5,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,70.28,138,
HOLTER MCOT 15-30 DAYS PRO FEE,5500019,CDM,976,RC,93228,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,17.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,17.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,17.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,17.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,17.78,17.78,
BB ADSORPTION,3000044,CDM,300,RC,86978,HCPCS,outpatient,,,231,173.25,,184.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,29.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,10.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,10.6,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.6,184.8,
US BREAST UNILATERAL -RT LIMITED,4100044,CDM,402,RC,76642,HCPCS,outpatient,,,231,173.25,,184.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.05,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.93,184.8,
US BREAST UNILATERAL - LEFT LIMITED,4100045,CDM,402,RC,76642LT,HCPCS,outpatient,,,231,173.25,,184.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.05,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,92.95,184.8,
PARATHYROID HORMONE INTACT,2800470,CDM,301,RC,83970,HCPCS,outpatient,,,232,174,,185.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,127.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.64,185.6,
SFMC PARATHYROID HORMONE INTACT,2801148,CDM,301,RC,83970,HCPCS,outpatient,,,232,174,,185.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.64,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,127.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,53.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% UHC fee schedule for outpatient setting,41.28,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,66.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.92,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.64,185.6,
PR CT LOWER EXT WITH RT,4310022,CDM,972,RC,73701RT26,HCPCS,outpatient,,,232,174,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,139.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,139.2,139.2,
PR CT PELVIS WITH,4310034,CDM,972,RC,7219326,HCPCS,outpatient,,,232,174,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,139.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,139.2,139.2,
PR CT LOWER EXT WITH LT,4310061,CDM,972,RC,7370126LT,HCPCS,outpatient,,,232,174,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,139.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,139.2,139.2,
REMOVAL OF SKIN TAG UP TO 15,6200323,CDM,361,RC,11200,HCPCS,outpatient,,,232,174,,185.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,93.36,266.88,
ALDOSTERONE 24 HR URINE,2800035,CDM,301,RC,82088,HCPCS,outpatient,,,233,174.75,,186.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20.37,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,128.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,52.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,40.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,65.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.37,186.4,
OBSERVATION CARE DICHARGE DAY MANAGEMENT,6200026,CDM,510,RC,99217,HCPCS,outpatient,,,233,174.75,,186.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,93.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,93.76,186.4,
DESTRUCTION OF VAGINAL LESION(S); SIMPLE,6100552,CDM,521,RC,57061,HCPCS,outpatient,,,234,175.5,,187.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.16,4178.79,
SUBSEQUENT HOSPITAL CARE PER DAY-LEVEL2,6200040,CDM,510,RC,99232,HCPCS,outpatient,,,234,175.5,,187.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.16,187.2,
HOSPITAL DISCHARGE,6200371,CDM,510,RC,99238,HCPCS,outpatient,,,234,175.5,,187.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,94.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.16,187.2,
NEB SUBSEQUENT,5200052,CDM,410,RC,9464076,HCPCS,outpatient,,,235,176.25,,188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.56,188,
PREV MED NP 65+,6000271,CDM,521,RC,99387,HCPCS,outpatient,,,235,176.25,,188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.56,188,
PREV MED NP 65+,6100372,CDM,521,RC,99387,HCPCS,outpatient,,,235,176.25,,188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.56,188,
ANNUAL WELLNESS VISIT SUBSEQUENT,6900101,CDM,510,RC,G0439,HCPCS,outpatient,,,235,176.25,,188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,129.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,94.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,197.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,123.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.56,197.02,
CATHETER DILATATION AB35W07040135,90001150,CDM,278,RC,C1725,HCPCS,both,,,235.62,176.72,,188.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,94.81,235.62,
FHC-TRIM SKIN LESION,6900004,CDM,982,RC,11055,HCPCS,outpatient,,,238,178.5,,,,,,other,Not separately reimbursable for physician setting,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,142.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,15.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,15.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,15.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,15.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,15.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,25.25,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,15.78,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,22.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,15.78,142.8,
FHC-RIM BENIGN SKIN LESION 2-4 LESION,6900005,CDM,982,RC,11056,HCPCS,outpatient,,,238,178.5,,,,,,other,Not separately reimbursable for physician setting,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,142.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,21.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,21.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,34.8,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,21.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,30.45,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,21.75,142.8,
ANES INJ ANEST AGNT; AXILLARY NERVE,7200063,CDM,370,RC,64417,HCPCS,outpatient,,,238,178.5,,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1259.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1180.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,95.77,1259.46,
BK VIRUS URINE REAL-TIME PCR,2800782,CDM,301,RC,87799,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,132,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.55,192,
SFMC MAYO NOCARDIA SUSCEPTIBILITY,2801358,CDM,306,RC,87186,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,132,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,192,
BB BLOOD-FFP,3000010,CDM,383,RC,P9017,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,85.47,192,
BB AB IDENTIFICATION,3000020,CDM,300,RC,8687091,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.58,192,
BB AB ID CHEMICAL MODIFICATION,3000023,CDM,300,RC,86970,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.6,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,192,
PR MRA HEAD W/O CONTRAST,4210003,CDM,972,RC,7054426,HCPCS,outpatient,,,240,180,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,144,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,144,144,
PR MRA NECK W/CONTRAST,4210005,CDM,972,RC,7054826,HCPCS,outpatient,,,240,180,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,144,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,144,144,
PR MRA NECK W/O CONTRAST,4210006,CDM,972,RC,7054726,HCPCS,outpatient,,,240,180,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,144,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,144,144,
PR CT LOWER EXT W & WO RT,4310021,CDM,972,RC,7370226RT,HCPCS,outpatient,,,240,180,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,144,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,144,144,
PT EVALUATION LOW COMPLEXITY,5100512,CDM,424,RC,97161GP,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,192,
PT EVALUATION MODERATE COMPLEXITY,5197162,CDM,424,RC,97162GP,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,192,
PT EVALUATION HIGH COMPLEXITY,5197163,CDM,424,RC,97163GP,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,192,
EMG 4 EXT,5600013,CDM,922,RC,95864,HCPCS,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.58,214.92,
3RD ORDER BELOW(UPPER EXT),5800006,CDM,480,RC,,,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,276,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,276,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,276,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,441.6,
6FR MULTIPAK ANG,5800007,CDM,271,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
6FR MULTIPAK ANG-PIGTAIL,5800008,CDM,271,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
6FR MULTIPAK STR-PIGTAIL,5800009,CDM,271,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
ASXL1 TARGETED SEQUENCE ANALYS,2800452,CDM,310,RC,81176,HCPCS,outpatient,,,241,180.75,,192.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,637,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,637,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,637,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,120.95,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,132.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,314.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,314.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,314.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,314.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,314.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,314.47,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,192.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,96.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,387.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,241.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,192.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.98,637,
ACIST HD CONTROL(ACISTHDCON),5800011,CDM,271,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ACIST MANIFOLD(ACISTMANF),5800012,CDM,271,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ACIST SYRINGE (ACISTSYR),5800013,CDM,271,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
CALPROTECTIN FECAL,2800954,CDM,301,RC,83993,HCPCS,outpatient,,,241.5,181.13,,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,132.83,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.81,193.2,
SFMC CALPROTECTIN FECAL,2801289,CDM,301,RC,83993,HCPCS,outpatient,,,241.5,181.13,,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.48,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,132.83,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.52,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.81,193.2,
HLA B27,2800357,CDM,302,RC,81374,HCPCS,outpatient,,,243,182.25,,194.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,191.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,191.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.16,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,133.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,96.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,96.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.33,100,,,fee schedule,100% UHC fee schedule for outpatient setting,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,118.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,74.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,37.16,194.4,
DES-Y-CARBOXY PROTHROMBIN,2800837,CDM,301,RC,83951,HCPCS,outpatient,,,243,182.25,,194.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,200.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,200.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,200.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,133.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,103.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.2,200.58,
BACTERIA FILTER,5200018,CDM,270,RC,95819,HCPCS,outpatient,,,243,182.25,,194.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,182.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,97.78,413.89,
PT EVAL: LOW COMPLEXITY; TYPICALLY 20MIN,5100637,CDM,424,RC,97162GP,HCPCS,outpatient,,,244,183,,195.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,195.2,
ER VISIT LEVEL IV,6100350,CDM,521,RC,9928425,HCPCS,outpatient,,,244,183,,195.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,98.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.19,195.2,
EVALUATION SWALLOWING FUNCTION,2800270,CDM,440,RC,92610GN,HCPCS,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,196,
ANGIOSEAL VIP 6FR,5800022,CDM,271,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
CLOSURE DEVICE,5800023,CDM,278,RC,,,both,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,500,
HEP B VIRAL DNA TITER,2800336,CDM,301,RC,82397,HCPCS,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7.06,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.36,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.31,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,21.18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.31,196,
HEREDITARY HEMOCHROMATOSIS,2801304,CDM,305,RC,81256,HCPCS,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,172.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,172.11,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.68,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,84.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,84.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% UHC fee schedule for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.68,196,
VENOFER 100MG/5ML INJ,3200913,CDM,636,RC,J1756,HCPCS,both,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,245,
XR GALL BLADDER/OR,4000064,CDM,320,RC,74300TC,HCPCS,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
BALL PUMP INS,5800028,CDM,480,RC,33967,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,3199.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3199.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3199.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,3199.76,3199.76,
PR CT L-SPINE WITH,4310025,CDM,972,RC,7213226,HCPCS,outpatient,,,245,183.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,147,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,147,147,
BS GW IQ MARKER,5800030,CDM,270,RC,,,outpatient,,,320,240,,256,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.77,256,
BS  ABBOTT  PI BALLOONS,5800031,CDM,270,RC,,,outpatient,,,630,472.5,,504,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,253.51,504,
BS-PI BALLOONS DT/3 4 5 6,5800032,CDM,270,RC,,,outpatient,,,396,297,,316.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,159.35,316.8,
BS-PI BALLOONS F/G STERLING MR,5800033,CDM,270,RC,,,outpatient,,,658,493.5,,526.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,264.78,526.4,
BS-PI BALLOONS STERLING ES MR,5800034,CDM,270,RC,,,outpatient,,,628,471,,502.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,252.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,314,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,314,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,314,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,252.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,471,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,502.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,252.71,502.4,
BS-PI BALLOONS SYNERGY,5800035,CDM,270,RC,,,outpatient,,,340,255,,272,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,136.82,272,
BS-PI BALLOONS UT SDS,5800036,CDM,270,RC,,,outpatient,,,396,297,,316.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,159.35,316.8,
BS-PI CUTTING BALLOON PCB FLEXTOME MR,5800037,CDM,270,RC,,,outpatient,,,1650,1237.5,,1320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,907.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,663.96,1320,
BS-PI EXPRESS SD EXP SD RENAL BILLARY,5800038,CDM,270,RC,,,outpatient,,,2520,1890,,2016,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1014.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1386,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1014.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1014.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1890,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1014.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1014.05,2016,
BS-PI GUIDE CATHETERS PV MACH1,5800039,CDM,270,RC,,,outpatient,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,153.6,
BS-PI GUIDEWIRES MAGICTQ,5800040,CDM,270,RC,,,outpatient,,,328,246,,262.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.99,262.4,
BS-PI GUIDEWIRES THRUWAY 190CM/SHORT,5800041,CDM,270,RC,,,outpatient,,,216,162,,172.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.92,172.8,
BS-PI GUIDWIRES THRUWAY 300CM/SHORT,5800042,CDM,270,RC,,,outpatient,,,226,169.5,,180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.94,180.8,
BS-PI INFLATION DEVICES ENCORE,5800043,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
BS-PI SENTINOL MODEL-SENTINOL BIL,5800044,CDM,270,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
PR CT UPPER EXT W & WO RT,4310043,CDM,972,RC,7320226RT,HCPCS,outpatient,,,245,183.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,147,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,147,147,
CARDIAC EVENT RECORDER,5800046,CDM,275,RC,,,outpatient,,,7000,5250,,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3850,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5600,
PR CT C-SPINE WITH,4310051,CDM,972,RC,7212626,HCPCS,outpatient,,,245,183.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,147,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,147,147,
NW PT HOME VISIT LEVEL 5,6100480,CDM,522,RC,99345,HCPCS,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
CARDIVA CATALYST III CLOSURE DEVICE,5800049,CDM,271,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
INTRAOPERATIVE CHOLANGIOGRAM,6200471,CDM,360,RC,74300,HCPCS,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,196,
CATHETER HNBR 4.1-35-100-P-NS-DAV,5800051,CDM,271,RC,,,outpatient,,,56,42,,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.53,44.8,
SHAVE SKIN LESION >2.0 CM,6200584,CDM,360,RC,11303,HCPCS,outpatient,,,245,183.75,,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,134.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,183.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.59,551.37,
DO NOT USE,43102025,CDM,972,RC,7213226,HCPCS,outpatient,,,245,183.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,147,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,147,147,
CHRONIC TOLTAL OCCLUSION WIRES,5800054,CDM,270,RC,,,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,216,
Meningococcal recom lipoprotein 2-3 DOSE,6000201,CDM,636,RC,90621,HCPCS,both,,,246,184.5,,196.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.99,246,
OBSERVARTION  ADM/DC SAME DAY,6100330,CDM,982,RC,99235,HCPCS,outpatient,,,246,184.5,,,,,,other,Not separately reimbursable for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,147.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,248.83,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,217.73,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,115.99,248.83,
COPILOT/INDEFLATOR KIT,5800057,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
Meningococcal recom lipoprotein 2-3 DOSE,6100557,CDM,636,RC,90621,HCPCS,both,,,246,184.5,,196.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.99,246,
AMINO ACID-BLOOD QUALITATIVE,2800056,CDM,301,RC,82128,HCPCS,outpatient,,,247.5,185.63,,198,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.93,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,136.13,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,18.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,18.03,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,198,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.87,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.87,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,22.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,198,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.93,198,
ATHRECTOMY CATHETER,5800060,CDM,270,RC,,,outpatient,,,7000,5250,,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3850,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5600,
PR CT CHEST WITH,4310011,CDM,972,RC,7126026,HCPCS,outpatient,,,248,186,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,148.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,148.8,148.8,
REMOVAL OF DEVITALIZED TISSUE FROM WOUND,6000248,CDM,521,RC,97602,HCPCS,outpatient,,,248,186,,198.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.8,302.24,
NEGATIVE PRESSURE WOUND VAC,6000327,CDM,521,RC,97606,HCPCS,outpatient,,,248,186,,198.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,201.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,201.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.8,551.37,
DEPO-PROVERA,6000328,CDM,521,RC,J1050,HCPCS,outpatient,,,248,186,,198.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.8,198.4,
REMOVAL OF DEVITALIZED TISSUE FROM WOUND,6100459,CDM,521,RC,97602,HCPCS,outpatient,,,248,186,,198.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,186,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,99.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.8,302.24,
HYSTEROSALPINGOGRAPHY SUPRVSN & INTERPR,4000212,CDM,320,RC,74740,HCPCS,outpatient,,,249,186.75,,199.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,355.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,355.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,355.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,215.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,186.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,100.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,215.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.2,368.21,
SPEECH DYSPHASIA THERAPY,2800253,CDM,440,RC,92526GN,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,200,
HERPES CULTURE,2800347,CDM,306,RC,87255,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,119.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.57,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.93,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,44.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,44.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,33.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.86,100,,,fee schedule,100% UHC fee schedule for outpatient setting,33.86,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,54.17,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.93,200,
RNP,2800541,CDM,302,RC,86235,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.96,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.31,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% UHC fee schedule for outpatient setting,15.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.96,200,
VIRAL CULTURE,2800645,CDM,306,RC,87252,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.03,200,
GAMMA HYDROXYBUTYRIC ACID URINE,2801055,CDM,301,RC,80307,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,169.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.07,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.78,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,31.07,200,
SFMC VIRAL CULTURE,2801310,CDM,306,RC,87252,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,92.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.03,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,33.89,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% UHC fee schedule for outpatient setting,26.07,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,39.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.03,200,
GUIDE CATHETERS-VIKING,5800073,CDM,270,RC,,,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.26,88,
GUIDE EMERALD J-TIP .035X260CM 502-455,5800074,CDM,271,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
ICD DUEL/SING GENERATOR,5800075,CDM,275,RC,,,outpatient,,,26000,19500,,20800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10462.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10462.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10462.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10462.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,20800,
ILIAC ANGIOGRAPHY,5800076,CDM,480,RC,,,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,720,
PENTAMIDINE ISETHIONATE INH. SOLN 300MG,3208086,CDM,636,RC,J2545,HCPCS,both,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,250,
PR MRI BRAIN W/O CONTRAST,4210017,CDM,972,RC,7055126,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR MRI CHEST W/O CONTRACT,4210022,CDM,972,RC,7155026,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR MRI LOWER EXTREMITY NOT JT W/O CON RT,4210026,CDM,972,RC,73718RT26,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR MRI ORBIT/FACE/NECK W/O CONTRAST,4210035,CDM,972,RC,7054026,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR MRI UPPER EXT JOINT W/O CONTRAST RT,4210045,CDM,972,RC,7322126RT,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR MRI UPPER EXTREMITY NOT JT W/O RT,4210048,CDM,972,RC,73218RT26,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR MRI UPPER EXT JT W/O CONTRAST LT,4210058,CDM,972,RC,7322126LT,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR MRI UPPER EXTREMITY NOT JT W/O LT,4210065,CDM,972,RC,73218LT26,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT BRAIN WITH,4310008,CDM,972,RC,7046026,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT NECK WITHOUT,4310030,CDM,972,RC,7049026,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT PELVIS WITH & WO,4310035,CDM,972,RC,7219426,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT SINUSES WITH & WO,4310038,CDM,972,RC,7048826,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT T-SPINE W & WO,4310040,CDM,972,RC,7213026,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT UPPER EXT WITH RT,4310044,CDM,972,RC,7320126RT,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT LOWER EXT W & WO LT,4310060,CDM,972,RC,7370226LT,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR CT UPPER EXT W & WO LT,4310064,CDM,972,RC,7320226LT,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR NM RENAL FLOW MULTIPLE STUDIES,4410049,CDM,972,RC,7870926,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
PR NM STRESS AND REST STUDY BOTH,4410056,CDM,972,RC,7845226,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
OT EVALUATION HIGH COMPLEXITY,5100002,CDM,434,RC,97167GO,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,200,
OT RE EVALUATION MOD COMP; RE EVALUATION,5100013,CDM,434,RC,97166GO,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,200,
ST TREATMENT OF SWALLOW DYSFUNCTION,5100530,CDM,440,RC,92526GN,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,200,
LHC/CORN/VENT,5800099,CDM,480,RC,,,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6800,
LHC-CATH PACK,5800100,CDM,271,RC,,,outpatient,,,128,96,,102.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.51,102.4,
ST INITIAL SWALLOW FUNCTION EVAL,5100531,CDM,440,RC,92610GN,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,200,
ST TREATMENT OF SPEEDH/LANG/VOICE,5100534,CDM,440,RC,92507GN,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,200,
OT EVALUATION LOW COMPLEXITY,5197165,CDM,434,RC,97165GO,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,200,
CATHETER EVERCROSS DILATATION,5890142,CDM,278,RC,C1725,HCPCS,both,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,250,
MICRO EZ 5FR (MICROINTRODUCER KIT),5800105,CDM,270,RC,,,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.26,88,
SHAVING LESION OVER 2CM FACE,6000119,CDM,521,RC,11313,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,551.37,
MYNX VASC CLOSE DEVICE,5800107,CDM,271,RC,,,outpatient,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,440,
REPAIR-SIMPLE 2.6CM TO 7.5CM,6000137,CDM,521,RC,12002,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,375.41,
SHAVING LESION OVER 2CM FACE,6100060,CDM,521,RC,11313,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,551.37,
REPAIR-SIMPLE 2.6CM TO 7.5CM,6100071,CDM,521,RC,12002,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,375.41,
CLOSED TREATMENT OF RADIAL FX,6100084,CDM,521,RC,25500,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,652.23,
DEFIB/PAC-SINGLE,5800112,CDM,275,RC,,,outpatient,,,25000,18750,,20000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13750,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,20000,
REMOVAL OF LYMPH NODE,6100094,CDM,360,RC,38500,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,5080.87,
CONIZATION OF CERVIX,6100134,CDM,969,RC,57522,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,168.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,248.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,248.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,248.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,248.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,168.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,168.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,248.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,248.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,168.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,397.54,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,248.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,347.84,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,150,397.54,
OFFICE OR OTHER O/P CONSULT-LEVEL 3,6200029,CDM,510,RC,99203,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,38,200,
DRAINAGE OF CHEST,6200092,CDM,360,RC,32000,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,200,
NASOPHARYNGOSCOPY,6200214,CDM,360,RC,92511,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,152.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,152.32,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264.17,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,264.17,
REMOVAL OF PEG TUBE,6200251,CDM,360,RC,43999,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,1529.37,
SIGMOIDOSCOPY W/BIOPSY,6200287,CDM,360,RC,45331,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,1228.22,
FNA W/IMAGE,6200341,CDM,510,RC,10022,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,200,
FNA W/IMAGE 1ST LESION,6200598,CDM,510,RC,10005,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,1845.77,
INJ PROC ONLY MAMMARY DUCTO /GALACTOGRAM,6200622,CDM,360,RC,19030,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,320.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,320.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,320.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,320.02,
CLOSED TREATMENT OF RADIAL FX,6300065,CDM,521,RC,25500,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,652.23,
PERC NDLE 18/7CM NDLPG00166,5800124,CDM,271,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
REPAIR-SIMPLE 2.6CM TO 7.5CM,6300124,CDM,521,RC,12002,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,375.41,
PERCLOSE A-T,5800126,CDM,271,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
PERCLOSE PROGLIDE,5800127,CDM,271,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
SHAVING LESION OVER 2CM FACE,6300130,CDM,521,RC,11313,HCPCS,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,551.37,
"INSERTION, NON-BIODEGRADEABLE DRUG DELIV",6900234,CDM,982,RC,11981,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,83.08,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.82,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,61.82,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.82,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.82,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.08,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.08,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,61.82,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,61.82,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.08,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,98.91,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,61.82,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,86.55,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,61.82,150,
"REMOVAL, NON-BIODEGRADEABLE DRUG DELIVER",6900235,CDM,982,RC,11982,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,117.12,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,73.2,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.48,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.2,150,
INPATIENT D/C MORE THAN 30 MINS,7000007,CDM,987,RC,99239,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,66.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,177.94,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,111.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,66.67,177.94,
SAME DAY ADMIT AND D/C 40 MINUTES,7000008,CDM,982,RC,99234,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,88.3,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,154.74,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,96.71,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,135.39,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,88.3,154.74,
OBSERVATION INITIAL CARE/DAY 70 MINS,7000013,CDM,982,RC,99220,HCPCS,outpatient,,,250,187.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,150,150,
WESTERN BLOT HIV CONFIRMATION,2800664,CDM,300,RC,86689,HCPCS,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,68.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,138.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.16,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.67,201.6,
SFMC CHG ONLY PLA2R - 2,2801392,CDM,300,RC,86255,HCPCS,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,138.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,201.6,
CONSULT OV LEVEL V,6100338,CDM,521,RC,99245,HCPCS,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,201.6,
ANOSCOPY AND BIOPSY,6200058,CDM,360,RC,46606,HCPCS,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,1600.47,
BIOPSY OF NAIL UNIT,6200066,CDM,360,RC,11755,HCPCS,outpatient,,,252,189,,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.4,959.13,
INT COMP (AGE 18-39),6900086,CDM,982,RC,99385,HCPCS,outpatient,,,252,189,,,,,,other,Not separately reimbursable for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,91.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,151.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,91.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,91.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,91.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,76.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,146.69,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,91.68,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,128.35,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,76.67,151.2,
PR CT ABDOMEN WITH,4310005,CDM,972,RC,7416026,HCPCS,outpatient,,,253,189.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,151.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,151.8,151.8,
PR CT C-SPINE W & WO,4310014,CDM,972,RC,7212726,HCPCS,outpatient,,,253,189.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,151.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,151.8,151.8,
PTA TIBIO/PERONL EACH ADD,5800142,CDM,480,RC,,,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,4800,
TX-IRRIGATION BLADDER,1600008,CDM,761,RC,51700,HCPCS,outpatient,,,254,190.5,,203.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,102.21,317.56,
EVAL RX FOR COMMNICTN DEVICE 1ST HOUR,5100634,CDM,440,RC,92607GN,HCPCS,outpatient,,,254,190.5,,203.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,203.2,
"REPAIR LCRTN SIMPL FACE, EAR, EYE <2.5CM",6100700,CDM,521,RC,12011,HCPCS,outpatient,,,254,190.5,,203.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,102.21,375.41,
EXC BENIGN LESION TRUNK ARMS LEGS<0.5CM,6200113,CDM,360,RC,11400,HCPCS,outpatient,,,254,190.5,,203.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,102.21,959.13,
PR CT L-SPINE WITH & WO,4310026,CDM,972,RC,7213326,HCPCS,outpatient,,,255,191.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,153,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,153,153,
SHAVE LESION 1.1-2.0CM,6200503,CDM,360,RC,11312,HCPCS,outpatient,,,255,191.25,,204,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,102.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,102.61,551.37,
PR CT ORBITS WITHOUT,4310033,CDM,972,RC,7048026,HCPCS,outpatient,,,256,192,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,153.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,153.6,153.6,
MENACTRA VACCINE,6900055,CDM,982,RC,90734,HCPCS,outpatient,,,257,192.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,154.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,154.2,154.2,
THYROID STIMULATING IMMUNOGLOBULIN,2800603,CDM,300,RC,84445,HCPCS,outpatient,,,258,193.5,,206.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,141.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,81.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.05,206.4,
SFMC THYROID STIMULATING IMMUNOGLOBULIN,2801235,CDM,300,RC,84445,HCPCS,outpatient,,,258,193.5,,206.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,64.98,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,25.43,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,141.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,66.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% UHC fee schedule for outpatient setting,25.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,81.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,76.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.05,206.4,
REMOVAL CERUMEN,1400168,CDM,450,RC,69210,HCPCS,outpatient,,,259,194.25,,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,207.2,
EXCISION LESION 0.5CM OR LESS,6200143,CDM,360,RC,11420,HCPCS,outpatient,,,259,194.25,,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.22,2216.25,
QUIK COMBO ECG PADS,5800155,CDM,271,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
SFMC CPT 81241 CHG ONLY,2800899,CDM,301,RC,81241,HCPCS,outpatient,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,160.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,36.68,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,143,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,95.38,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,73.37,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,117.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.68,208,
PR US ECHOCARDIOGRAM,4010171,CDM,972,RC,9330626,HCPCS,outpatient,,,260,195,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,156,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,156,156,
PR MRA NECK W/W/O CONTRAST,4210007,CDM,972,RC,7054926,HCPCS,outpatient,,,260,195,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,156,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,156,156,
RENAL ANGIO W/ CATH,5800159,CDM,480,RC,,,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,720,
NM PH TC99M ULTRA TAG RBC KIT,4400037,CDM,343,RC,A9560,HCPCS,outpatient,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.62,208,
NEB INITIAL,5200028,CDM,410,RC,94640,HCPCS,outpatient,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.33,283.02,
EXCISION OF NAIL PARTIAL OR COMP,6000130,CDM,521,RC,11750,HCPCS,outpatient,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.62,786.48,
RHOGAM,6000308,CDM,636,RC,J2790,HCPCS,both,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.62,260,
EXCISION OF NAIL PARTIAL OR COMP,6100066,CDM,521,RC,11750,HCPCS,outpatient,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.62,786.48,
RHOGAM,6100255,CDM,636,RC,J2790,HCPCS,both,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.62,260,
SIGMOIDOSCOPY & BIOPSY,6100544,CDM,521,RC,45331,HCPCS,outpatient,,,260,195,,208,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,104.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.62,1228.22,
FACTOR X ACTIVITY,2800273,CDM,300,RC,85260,HCPCS,outpatient,,,261,195.75,,208.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,49.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.94,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,143.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.27,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,28.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.94,208.8,
FACTOR IX ANTIGEN,2800970,CDM,300,RC,85250,HCPCS,outpatient,,,261,195.75,,208.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,143.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.52,208.8,
FACTOR IX ACTIVITY,2801278,CDM,300,RC,85250,HCPCS,outpatient,,,261,195.75,,208.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,67.22,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,143.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.75,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.52,208.8,
XR FLUORO CVA PLACEMENT,4000056,CDM,320,RC,77001,HCPCS,outpatient,,,261,195.75,,208.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.55,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,208.8,
INT COMP (AGE 12-17),6900085,CDM,982,RC,99384,HCPCS,outpatient,,,261,195.75,,,,,,other,Not separately reimbursable for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,156.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,86.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,152.45,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,133.39,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,86.25,156.6,
LUMBAR PUNCTURE:DIAGNOSTIC,1400151,CDM,450,RC,62270TC,HCPCS,outpatient,,,262,196.5,,209.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.43,429.76,
PR LUMBAR PUNCTURE:DIAGNOSTIC,1410151,CDM,972,RC,6227026,HCPCS,outpatient,,,262,196.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,157.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,157.2,157.2,
XR ANKLE ARTHROGRAM,4000027,CDM,322,RC,73615TC,HCPCS,outpatient,,,262,196.5,,209.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.1,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.43,209.6,
PREV MED EST 65+,6900094,CDM,982,RC,99397,HCPCS,outpatient,,,262,196.5,,,,,,other,Not separately reimbursable for physician setting,81.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,157.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,81.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,81.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,81.88,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,152.45,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,95.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,133.39,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,81.88,157.2,
SHEATHS ALL SIZES,5800176,CDM,271,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
FACTOR XIII ACTIVITY,2801408,CDM,302,RC,85291,HCPCS,outpatient,,,262.5,196.88,,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.55,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,144.38,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.84,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,9.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,196.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.11,100,,,fee schedule,100% UHC fee schedule for outpatient setting,9.11,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.66,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.55,210,
INJECTION GLUCAGON HCI 1MG,4000002,CDM,636,RC,J1610,HCPCS,both,,,263,197.25,,210.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.83,300,
OT EVAL: MODERATE COMPLEXITY; TYP 45MINS,5100638,CDM,430,RC,97166GO,HCPCS,outpatient,,,263,197.25,,210.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,210.4,
GUIDEWIRE 3.2MM X 300,890018,CDM,278,RC,C1769,HCPCS,both,,,263.74,197.81,,210.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.13,263.74,
FINGER SPLINT,1400090,CDM,450,RC,29130,HCPCS,outpatient,,,264,198,,211.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,145.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,211.2,
STENT PLACED EACH ADD,5800182,CDM,480,RC,,,outpatient,,,11278,8458.5,,9022.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5639,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5639,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5639,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6202.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9022.4,
ER FX CARE SPLINT STATIC,1400091,CDM,450,RC,29130,HCPCS,outpatient,,,264,198,,211.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,145.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,211.2,
INTIAL PREV EXAM; FIRST 12 MONTHS MCARE,6100725,CDM,521,RC,G0402,HCPCS,outpatient,,,264,198,,211.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.88,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,111.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,145.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,106.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,111.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,167.45,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,104.24,211.2,
REMVL IMPCT CERUMEN IRRIGTN/LAVAGE UNILA,6900022,CDM,982,RC,69209,HCPCS,outpatient,,,264,198,,,,,,other,Not separately reimbursable for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,158.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,8.66,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,21.98,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,13.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,19.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,8.66,158.4,
TEMP PACEMAKER,5800186,CDM,480,RC,,,outpatient,,,8856,6642,,7084.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4870.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7084.8,
TERUMO GLIDECATH,5800187,CDM,270,RC,,,outpatient,,,216,162,,172.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.92,172.8,
PUNCH BIOPSY SINGLE LESION,6900250,CDM,982,RC,11104,HCPCS,outpatient,,,264,198,,,,,,other,Not separately reimbursable for physician setting,87.86,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,158.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,45.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,45.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,87.86,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,87.86,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,45.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,45.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,87.86,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,73.04,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,45.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,63.91,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,45.65,158.4,
THORACENTESIS W/O IMAGING GUIDANCE PRO F,7000039,CDM,982,RC,32554,HCPCS,outpatient,,,264,198,,,,,,other,Not separately reimbursable for physician setting,361.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,86.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,158.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,86.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,86.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,86.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,361.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,361.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,86.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,86.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,361.25,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,138.62,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,86.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,121.3,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,86.64,361.25,
HUMAN HERPES VIRUS 6,2800948,CDM,300,RC,87532,HCPCS,outpatient,,,265,198.75,,212,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,145.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,212,
INVANZ 1GM INJ,3200412,CDM,636,RC,J1335,HCPCS,both,,,265,198.75,,212,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.64,265,
XR ACUTE ABD SERIES+1V CHEST*,4000024,CDM,320,RC,74022TC,HCPCS,outpatient,,,265,198.75,,212,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.64,212,
XR LUMBAR SPINE COMPLETE W BENDING,4000082,CDM,324,RC,72114TC,HCPCS,outpatient,,,265,198.75,,212,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.64,212,
XR SKULL COMP MIN 4 VIEWS,4000115,CDM,320,RC,70260TC,HCPCS,outpatient,,,265,198.75,,212,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.64,212,
VISION-BARE METAL STENT,5800195,CDM,270,RC,,,outpatient,,,1890,1417.5,,1512,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,760.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,945,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,945,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,945,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1039.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,760.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1417.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,760.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,760.54,1512,
XR ABD 3/VIEW*,4001145,CDM,320,RC,74021TC,HCPCS,outpatient,,,265,198.75,,212,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.64,212,
WIRES,5800197,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
IND/THERAPY 75-80 MIN,6600008,CDM,914,RC,90808,HCPCS,outpatient,,,265,198.75,,212,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,106.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.64,212,
PRO FEE IND/THERAPY 75-80 MIN,6600016,CDM,960,RC,90808,HCPCS,outpatient,,,265,198.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,159,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,159,159,
COLPOSCOPY OF VULVA W/BIOPSY,6900231,CDM,982,RC,56821,HCPCS,outpatient,,,265,198.75,,,,,,other,Not separately reimbursable for physician setting,95.37,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,112.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,159,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,112.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,112.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,112.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,95.37,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,95.37,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,112.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,112.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,95.37,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,179.39,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,112.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,156.97,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,95.37,179.39,
LEVEL 1-CARDIAC WITH RUNOFF,5800201,CDM,360,RC,,,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6800,
STENT MEDINOL (NXL30017US,5890000,CDM,270,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
WEST NILE VIRUS ULTRA-QUAL,2800718,CDM,302,RC,87798,HCPCS,outpatient,,,266,199.5,,212.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,146.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,212.8,
XR RIBS BILATERAL 3 VIEW,4000101,CDM,324,RC,71110TC,HCPCS,outpatient,,,266,199.5,,212.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.04,212.8,
WORK HARDENING; INITIAL 2 HOURS,5100542,CDM,420,RC,97545GP,HCPCS,outpatient,,,266,199.5,,212.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,212.8,
WORK HARDENING; INITIAL 2 HOURS,5100543,CDM,430,RC,97545GO,HCPCS,outpatient,,,266,199.5,,212.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,70,100,,,case rate,100% Coventry therapy case rate for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70,212.8,
CHEMICAL PLEURODESIS(RECUR PNEUMOTHORAX),6200076,CDM,360,RC,32560,HCPCS,outpatient,,,266,199.5,,212.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.04,1055.7,
BIOPSY OF THYROID,6200460,CDM,360,RC,60100,HCPCS,outpatient,,,266,199.5,,212.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,199.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.04,959.13,
VANCOMYCIN 2GM/400ML  PREMIX,3206332,CDM,636,RC,J3370,HCPCS,both,,,266.5,199.88,,213.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.24,266.5,
LOVENOX 80MG/0.8mL INJ,3200516,CDM,636,RC,J1650,HCPCS,both,,,267.5,200.63,,214,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.64,267.5,
HEPATITIS SCREEN W/ REFLEX,2800344,CDM,301,RC,80074,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,168.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,168.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,168.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,147.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,76.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.81,214.4,
SFMC HEPATITIS SCREEN,2801130,CDM,301,RC,80074,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,168.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,168.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,168.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,23.81,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,147.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,61.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% UHC fee schedule for outpatient setting,47.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,76.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.44,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.81,214.4,
US BREAST UNILATERAL LIM,4100009,CDM,402,RC,76642,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.93,214.4,
US BREAST COMPLETE RT,4100051,CDM,402,RC,76641RT,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.84,214.4,
US BREAST COMPLETE LT,4100052,CDM,402,RC,76641LT,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.84,214.4,
"OT ATHLETIC TRAINING EVAL, LOW COMPLEX",5197169,CDM,951,RC,97169GO,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.84,214.4,
"OT ATHLETIC TRAINING, MODERATE COMPLEX",5197170,CDM,951,RC,97170GO,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.84,214.4,
"OT ATHLETIC TRAINING EVAL, HIGH COMPLEX",5197171,CDM,951,RC,97171GO,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.84,214.4,
"TRANSVERSUS ABDOMINIS PLNE,TAP BLK BILAT",7200064,CDM,370,RC,64488,HCPCS,outpatient,,,268,201,,214.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,741.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,741.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,741.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,107.84,741.29,
XR T-TUBE CHOLANGIOGRAM,4000127,CDM,320,RC,74327TC,HCPCS,outpatient,,,269,201.75,,215.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.25,215.2,
INT I/P CONSULT V,6100343,CDM,521,RC,99255,HCPCS,outpatient,,,269,201.75,,215.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.25,215.2,
DIAGNOSTIC LARYNGOSCOPY,6200463,CDM,360,RC,31575,HCPCS,outpatient,,,269,201.75,,215.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,273.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,273.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,273.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264.17,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.25,273.93,
KWIRE 1210-6450S,890044,CDM,278,RC,C1769,HCPCS,both,,,269.9,202.43,,215.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.61,269.9,
CRICOTHROTOMY,1400121,CDM,450,RC,31505,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,152.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,152.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264.17,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,165.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,264.17,
METANEPHRINE,2800423,CDM,301,RC,83835,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,216,
METANEPHRINES PLASMA FREE,2800424,CDM,300,RC,83835,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,216,
SFMC METANEPHRINE 24 HR URINE,2801231,CDM,301,RC,83835,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,216,
SFMC METANEPHRINES PLASMA,2801253,CDM,300,RC,83835,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,59.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.47,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.41,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.47,216,
CATHETER NC TREK CORONARY DILATATION,5890032,CDM,272,RC,C1725,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,216,
CATHETER NC TREK CORONARY DILATATION,5890038,CDM,278,RC,C1725,HCPCS,both,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,270,
CATHETER TREK CORONARY DILATATION,5890060,CDM,278,RC,C1725,HCPCS,both,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,270,
CATHETER TREK CORONARY DILATATION,5890061,CDM,278,RC,C1725,HCPCS,both,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,270,
CATHETER TREK CORONARY DILATATION,5890079,CDM,270,RC,C1725,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,216,
CATHETER MINI TREK CORONARY,5890080,CDM,278,RC,C1725,HCPCS,both,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,270,
CATHETER MINI TREK CORONARY DILATATION,5890087,CDM,278,RC,C1725,HCPCS,both,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,270,
CATHETER CORONARY DILATATION,5890111,CDM,278,RC,C1725,HCPCS,both,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,270,
CATHETER NC TREK CORONARY DILATATION,5890145,CDM,272,RC,C1725,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,216,
DESTROY SKIN LESIONS-LEVEL 2,6200335,CDM,510,RC,17111,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,266.88,
REPLACEMENT OF PEG TUBE,6200365,CDM,510,RC,43762,HCPCS,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,737.3,
CATHETER TREK CORONARY DILATATION,90000345,CDM,278,RC,C1725,HCPCS,both,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,270,
ARTERIAL LINE INSERTION,5200016,CDM,410,RC,36620,HCPCS,outpatient,,,271,203.25,,216.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2111.54,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2111.54,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2111.54,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,109.05,2111.54,
CATH KIT INFINITI THRULUMEN 5F,5890044,CDM,278,RC,,,both,,,16.7,12.53,,13.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,16.7,
VERY LONG CHAIN FATTY ACID,2800638,CDM,300,RC,82726,HCPCS,outpatient,,,273,204.75,,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,150.15,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.68,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,204.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,218.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.87,218.4,
PR SHUNTOGRAM,4011162,CDM,972,RC,7580926,HCPCS,outpatient,,,273,204.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,163.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,163.8,163.8,
PR LIVER BIOPSY,1410240,CDM,972,RC,4700026,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
"FRAGILE X SYNDROME, CARRIER",2801444,CDM,311,RC,81243,HCPCS,outpatient,,,275,206.25,,220,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,151.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.26,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.52,220,
DO NOT USE,4000087,CDM,401,RC,G0206TCRT,HCPCS,outpatient,,,275,206.25,,220,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,110.66,220,
DO NOT USE,4000088,CDM,401,RC,G0206TCLT,HCPCS,outpatient,,,275,206.25,,220,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,110.66,220,
PR MRI ABDOMEN WITH CONTRAST,4210010,CDM,972,RC,7418226,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
PR MRI LOWER EXT JOINT W/O CONTRAST RT,4210023,CDM,972,RC,7372126RT,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
PR MRI CERVICAL SPINE W/CONTRAST,4210049,CDM,972,RC,7214226,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
PR MRI LOWER EXT JOINT W/O CONTRAST LT,4210054,CDM,972,RC,7372126LT,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
PR CT CHEST WITH & WO,4310012,CDM,972,RC,7127026,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
PR CT NECK WITH,4310028,CDM,972,RC,7049126,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
PR CT ORBITS WITH,4310031,CDM,972,RC,7048126,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
NM PH LEXICAN .1MG,4400068,CDM,636,RC,J2785,HCPCS,both,,,275,206.25,,220,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,110.66,275,
PR NM THYR RADIOPHAR. ORAL THERAPY,4410060,CDM,972,RC,7900526,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
REPAIR SUPERFICIAL WOUND 2.6CM TO7.5CM,6200275,CDM,360,RC,12002,HCPCS,outpatient,,,275,206.25,,220,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,151.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,110.66,375.41,
INITIAL HOSPITAL LEVEL 3,7000002,CDM,987,RC,99223,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,125.54,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,270.96,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,169.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,237.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,125.54,270.96,
SAME DAY ADMIT/D/C 50 MIN BEDSIDE,7000009,CDM,982,RC,99235,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,115.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,248.83,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,155.52,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,217.73,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,115.99,248.83,
PR CTA UPPER EXTREMITY UNILATERAL  W/WO,43100068,CDM,972,RC,7320626,HCPCS,outpatient,,,275,206.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165,165,
ER PLACEMENT OF SHOULDER IMMOBLIZER,1400157,CDM,450,RC,29240,HCPCS,outpatient,,,276,207,,220.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,151.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,220.8,
ER STRAPPING HIP,1400201,CDM,450,RC,29520,HCPCS,outpatient,,,276,207,,220.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,151.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,220.8,
XR SCOLIOSIS 2V,4001079,CDM,320,RC,72082TC,HCPCS,outpatient,,,276,207,,220.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.8,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,111.06,220.8,
PR XR VENOGRAM EXTREMITY UNILATERAL,4010133,CDM,972,RC,7582026,HCPCS,outpatient,,,276,207,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165.6,165.6,
PR MRA LOWER EXTREMITY WITH CONTRAST,4210071,CDM,972,RC,C8912,HCPCS,outpatient,,,276,207,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165.6,165.6,
PR MRA LOWER EXT W/O CONTRAST,4210077,CDM,972,RC,C8913,HCPCS,outpatient,,,276,207,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,165.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,165.6,165.6,
NM PH TETROFOSMIN (MYOVIEW)-PER DOSE,4400047,CDM,343,RC,A9502,HCPCS,outpatient,,,277,207.75,,221.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,111.46,221.6,
CATH KIT INFINITI THRULUMEN 5F DRC,5890071,CDM,278,RC,,,both,,,16.7,12.53,,13.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,16.7,
INJ LT VEN,5800079,CDM,480,RC,93452,HCPCS,outpatient,,,277,207.75,,221.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,207.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,111.46,8687.74,
STENT XIENCE SIERRA ELUTING,5890073,CDM,278,RC,,,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,965.76,1920,
ANTI-MOG ARUP,2801421,CDM,302,RC,86255,HCPCS,outpatient,,,277.5,208.13,,222,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.08,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,152.63,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.67,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,222,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,222,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.02,222,
ACHR MODULATING ANTIBODIES,2800025,CDM,300,RC,83519,HCPCS,outpatient,,,278,208.5,,222.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,152.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.33,222.4,
VARICELLA VACCINE,6900051,CDM,982,RC,90716,HCPCS,outpatient,,,278,208.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,166.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,166.8,166.8,
ANTINUCLEAR AB BY IFA WITH PATTERN,2801422,CDM,302,RC,86038,HCPCS,outpatient,,,279,209.25,,223.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,153.45,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,15.72,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,209.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.13,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,223.2,
PR BX LUNG/MED PERQ,4011152,CDM,973,RC,32405,HCPCS,outpatient,,,279,209.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,167.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,167.4,167.4,
PR Bx Lung Perqut,4210084,CDM,972,RC,32408,HCPCS,outpatient,,,279,209.25,,,,,,other,Not separately reimbursable for physician setting,609.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,148.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,167.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,148.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,148.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,148.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,609.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,609.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,148.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,148.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,609.39,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,238.03,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,148.77,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,208.28,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,148.77,609.39,
ER LEVEL 2,1400143,CDM,450,RC,99282,HCPCS,outpatient,,,280,210,,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,112.67,280,
ER LEVEL 2 - MODIFIER,1400144,CDM,450,RC,9928225,HCPCS,outpatient,,,280,210,,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,112.67,224,
PR MRI LUMB/SPINE W/O CONTRAST,4210027,CDM,972,RC,7214826,HCPCS,outpatient,,,280,210,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,168,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,168,168,
PR MRI LOWER EXTREMI NOT JT W/O CON LT,4210057,CDM,972,RC,7371826LT,HCPCS,outpatient,,,280,210,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,168,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,168,168,
PR CT ABDOMEN WITH & WO,4310006,CDM,972,RC,7417026,HCPCS,outpatient,,,280,210,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,168,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,168,168,
PR CT NECK WITH & WO,4310029,CDM,972,RC,7049226,HCPCS,outpatient,,,280,210,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,168,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,168,168,
NM PH TC99M NACRIAGG ALBU 10MILLICURIES,4400066,CDM,343,RC,Q9969,HCPCS,outpatient,,,280,210,,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,10,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10,224,
PUNCTURE ASPIRATION OF SCROTUM HYDROCELE,6200494,CDM,360,RC,55000,HCPCS,outpatient,,,280,210,,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,112.67,959.13,
C DIFF CYTOTOXIN ANTIBODY SERUM,2800956,CDM,301,RC,87230,HCPCS,outpatient,,,281,210.75,,224.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,69.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.86,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,154.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,25.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,25.66,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,19.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,19.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.86,224.8,
MENINGOCOCCAL VACCINE (BEXERO),6900054,CDM,982,RC,90733,HCPCS,outpatient,,,281,210.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,168.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,168.6,168.6,
COMPLEX REPAIR S/A/L ADD 5CM,6200475,CDM,360,RC,13122,HCPCS,outpatient,,,283,212.25,,226.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,141.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,113.88,226.4,
HIV RNA BY PCR QUANTITATIVE,2800356,CDM,301,RC,87536,HCPCS,outpatient,,,285,213.75,,228,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,300.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,300.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,300.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,42.55,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,156.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,110.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,110.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,110.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,110.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,110.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,110.63,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,85.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% UHC fee schedule for outpatient setting,85.1,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,136.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.55,300.46,
STENT SYS SIROLIMUS ELUTING CORONARY,5890092,CDM,278,RC,,,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
SCREW 2.7 LOCKING 22MM,890163,CDM,278,RC,C1713,HCPCS,both,,,286,214.5,,228.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.09,869.4,
ARTERIAL PUNCTURE,5200017,CDM,410,RC,36600,HCPCS,outpatient,,,287,215.25,,229.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,229.6,
CPT,5200021,CDM,410,RC,94668,HCPCS,outpatient,,,287,215.25,,229.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.33,229.6,
CONT INHALATION TX/MED 1ST HR,5200026,CDM,410,RC,94644,HCPCS,outpatient,,,287,215.25,,229.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.67,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,229.6,
STENT SIROLIMUS ELUTING 3.5MM 35MM,5890097,CDM,278,RC,C1874,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,0.01,0.01,
STENT SIROLIMUS ELUTING CORONARY 2.25MM/,5890098,CDM,278,RC,C1874,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,0.01,0.01,
HOLTER RECORDING/DISCONNECT TZ,5500007,CDM,731,RC,93225,HCPCS,outpatient,,,287,215.25,,229.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,157.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,215.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,229.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,229.6,
BIOPSY OF UTERUS LINING,58100,CDM,360,RC,58100,HCPCS,outpatient,,,288,216,,230.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.89,263.25,
XR IVP,4000072,CDM,320,RC,74400TC,HCPCS,outpatient,,,288,216,,230.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.89,230.4,
THORACENTESIS FOR ASPIRATION,6200396,CDM,360,RC,32421,HCPCS,outpatient,,,288,216,,230.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.89,230.4,
XR LOOPOGRAM,4000078,CDM,320,RC,74425TC,HCPCS,outpatient,,,289,216.75,,231.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.29,231.2,
PERQ DEV BREAST 1ST US LESION,6200488,CDM,360,RC,19285,HCPCS,outpatient,,,289,216.75,,231.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.29,959.14,
PR CT ORBITS WITH & WO,4310032,CDM,972,RC,7048226,HCPCS,outpatient,,,290,217.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,174,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,174,174,
DILATE ESOPHAGUS,6200088,CDM,360,RC,43450,HCPCS,outpatient,,,290,217.5,,232,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1004.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1004.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1004.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,159.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.7,1220.05,
ERYTHROCIN 500 MG INJ,3200295,CDM,636,RC,J1364,HCPCS,both,,,291,218.25,,232.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,83.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,83.64,291,
PICC LINE PLACEMENT PRO,7000037,CDM,982,RC,36569,HCPCS,outpatient,,,291,218.25,,,,,,other,Not separately reimbursable for physician setting,169.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,91.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,174.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,91.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,169.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,169.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,91.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,91.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,169.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,147.15,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,91.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,128.76,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,91.97,174.6,
TX-DECLOTTING,1600002,CDM,761,RC,36550,HCPCS,outpatient,,,293,219.75,,234.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,117.9,234.4,
INTERLEUKIN 6,2800387,CDM,300,RC,83520,HCPCS,outpatient,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,161.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,235.2,
PANCREATIC ELASTASE FECAL,2800466,CDM,300,RC,82656,HCPCS,outpatient,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,161.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,235.2,
SFMC PANCREATIC ELASTASE FECAL,2801288,CDM,300,RC,82656,HCPCS,outpatient,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,40.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5.76,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,161.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,14.99,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.76,235.2,
SFMC INTERLEUKIN 6,2801390,CDM,300,RC,83520,HCPCS,outpatient,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,161.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,235.2,
OMNIPAQUE 350 100 ML,3207547,CDM,636,RC,Q9967,HCPCS,both,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,118.31,294,
Meningococcal recombinant protein 2 dose,6000200,CDM,636,RC,90620,HCPCS,both,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,118.31,294,
Meningococcal recom prot 2 dose (BEXSERO,6100556,CDM,636,RC,90620,HCPCS,both,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,118.31,294,
NH ADMIT LEVEL 1,6200472,CDM,510,RC,99304,HCPCS,outpatient,,,294,220.5,,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,118.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,118.31,235.2,
Tumor immunohistochem/comput,2800952,CDM,301,RC,88361,HCPCS,outpatient,,,295,221.25,,236,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,258.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,105.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,105.39,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.39,479.01,
INTRODUCER 6F GLIDESHEATH SLENDER,5890119,CDM,270,RC,,,outpatient,,,189,141.75,,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.05,151.2,
CATHETER OPTITORQUE 5F JACKY DIAG CORONA,5890120,CDM,270,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
CATHETER OPTITORQUE 5F TIGER DIAG CORONA,5890121,CDM,270,RC,,,outpatient,,,116,87,,92.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,46.68,92.8,
US ARTERIAL  EXT FOR ABI ONLY,4100007,CDM,921,RC,93922TC,HCPCS,outpatient,,,295,221.25,,236,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,118.71,236,
ER DEBRIDMENT SKIN,1400056,CDM,450,RC,97597PO,HCPCS,outpatient,,,296,222,,236.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,148,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119.11,236.8,
ER REMOVE TISSUE SELECT DEBRID WO ANES,1400170,CDM,450,RC,97597,HCPCS,outpatient,,,296,222,,236.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119.11,266.87,
WOUND CARE SELECTIVE,1400258,CDM,761,RC,97597,HCPCS,outpatient,,,296,222,,236.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119.11,266.87,
INCISION AND DRAINAGE BARTHOLIN GLANDCY,6200189,CDM,360,RC,56420,HCPCS,outpatient,,,296,222,,236.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119.11,451.36,
Colposcopy exam of the cervix including,6900244,CDM,982,RC,57452,HCPCS,outpatient,,,296,222,,,,,,other,Not separately reimbursable for physician setting,70.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,89.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,177.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,89.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,89.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,89.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,70.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,89.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,89.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,142.43,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,89.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,124.63,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,70.45,177.6,
GUIDEWIRE CHOICE PT EXTRA SUPPORT W/ICE,5890129,CDM,278,RC,,,both,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,17,
SCAN/ANALYSIS/REPORT,5500013,CDM,731,RC,93226,HCPCS,outpatient,,,297,222.75,,237.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,119.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,237.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,237.6,
WEDGE EXCISION OF SKIN OF NAIL FOLD,6200319,CDM,360,RC,11765,HCPCS,outpatient,,,298,223.5,,238.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,119.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119.92,551.37,
REMOVAL SKIN TAGS UP TO 15,6900006,CDM,982,RC,11200,HCPCS,outpatient,,,298,223.5,,,,,,other,Not separately reimbursable for physician setting,48.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,178.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,48.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,72.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,72.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.16,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.25,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,72.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.84,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,48.16,178.8,
DESTRUCTION OF BENIGN LESIONS,6900013,CDM,982,RC,17110,HCPCS,outpatient,,,298,223.5,,,,,,other,Not separately reimbursable for physician setting,63.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,178.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,63.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,63.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,63.45,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,100.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,62.94,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,88.12,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.94,178.8,
ASPIRATE PLEURA W/O IMAGING,6200431,CDM,510,RC,32554,HCPCS,outpatient,,,299,224.25,,239.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,239.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,239.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.32,1313.87,
SCREW 4.0 CANN 42MM,890120,CDM,278,RC,C1713,HCPCS,both,,,299.2,224.4,,239.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.4,869.4,
SCREW 4.0 CANN 38MM,890121,CDM,278,RC,C1713,HCPCS,both,,,299.2,224.4,,239.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.4,869.4,
SCREW 4.0 CANN 34MM,890122,CDM,278,RC,C1713,HCPCS,both,,,299.2,224.4,,239.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.4,869.4,
SCREW 4.0 CANN 44MM,890125,CDM,278,RC,C1713,HCPCS,both,,,299.2,224.4,,239.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.4,869.4,
PR MRA ABD W CONTRAST,421001,CDM,972,RC,C890026,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
SCREW 4/0 CANN 55MM,890068,CDM,278,RC,C1713,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,869.4,
SCREW 4.0 CANN 60MM (604660S),890071,CDM,278,RC,C1713,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,869.4,
ADM WITH CHF CP ASTH,1400004,CDM,450,RC,99218,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
AVULSION/REMOVAL NAIL PLATE PART OR COM,1400016,CDM,450,RC,11730,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,266.88,
ER INITIAL TREATMENT 1ST DEGREE BURN,1400105,CDM,450,RC,16000,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,266.88,
ER LEVEL 1,1400141,CDM,450,RC,99281,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,69.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,104.03,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,64.76,300,
ER LEVEL 1 - MODIFIER,1400142,CDM,450,RC,9928125,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
ER REMOVE SKIN/FIBROCUT TAGS TO 15 CM,1400169,CDM,450,RC,11200,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,266.88,
STRAPPING KNEE,1400202,CDM,450,RC,29530,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,240,
GUIDING CATHETER XB C4 (67207400),5890149,CDM,270,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
GUIDING CATHETER XB 3.25 (67240000),5890150,CDM,270,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
IBD SPEC PANCA INDIRECT IFA IGG&DNA SENS,2800371,CDM,310,RC,88346,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,121.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,98.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,98.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,98.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,98.09,479.01,
LISTERIA ABS CSF,2801059,CDM,302,RC,86723,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,46.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.59,240,
ZYVOX 600MG PREMIXED,3201631,CDM,636,RC,J2020,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,300,
ZYVOX 600MG PREMIXED,3201632,CDM,636,RC,J2020,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,300,
ALBUMIN 25% 100ML,3202022,CDM,636,RC,P9047,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.62,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.08,300,
XR FLUORO-NEEDLE PLACEMENT,4000059,CDM,320,RC,77002,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,240,
PR MRA ABD W CONTRAST,4210001,CDM,972,RC,C8900,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRA HEAD W/CONTRAST,4210002,CDM,972,RC,7054526,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI LOWER EXT JOINT W/CONTRAST RT,4210012,CDM,972,RC,73722RT26,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI UPPER EXT JOINT W/CONTRAST RT,4210014,CDM,972,RC,73222RT26,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI BRAIN W/CONTRAST,4210016,CDM,972,RC,7055226,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI CHEST W/CONTRAST,4210021,CDM,972,RC,7155126,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI LOWER EXTR NOT JT W/CONTRAST RT,4210025,CDM,972,RC,7371926RT,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI ORBIT FACE AND NECK W/CONTRAST,4210033,CDM,972,RC,7054226,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI PELVIS W CONTRAST,4210036,CDM,972,RC,7219626,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI PELVIS W/O CONTRAST,4210037,CDM,972,RC,7219526,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI SPINAL CANAL CERVICAL W/CONTRAST,4210039,CDM,972,RC,7214226,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI SPINAL CANAL LUMBAR W/CONTRAST,4210040,CDM,972,RC,7214926,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI SPINAL CANAL THORACIC W/CONTRAST,4210041,CDM,972,RC,7214726,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI UPPER EXT NOT JT W CONTRAST RT,4210047,CDM,972,RC,73219RT26,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI LOWER EXT JOINT W/CONTRAST LT,4210051,CDM,972,RC,73722LT26,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI UPPER EXT JOINT W/CONTRAST LT,4210053,CDM,972,RC,73222LT26,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI LOWER EXTR NOT JT W/CONTRAST LT,4210056,CDM,972,RC,73719LT26,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRI UPPER EXT NOT JOINT W CONTRAST LT,4210066,CDM,972,RC,73219LT26,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRA CHEST W/O CONTRAST,4210075,CDM,972,RC,C8910,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRA LOWER EXT W CONTRAST,4210076,CDM,972,RC,7372526,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRA PELVIS W/O CONTRAST,4210079,CDM,972,RC,C8919,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR NM BRAIN-SPECT,4410008,CDM,972,RC,7860726,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
INSERT OF OCCLUSIVE DEVICE,5800084,CDM,480,RC,G0269,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,240,
INTRODUCTION OF CATH IN SVG/IVC,5800094,CDM,480,RC,36010,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,1101.24,
PICC LINE KIT,5800128,CDM,278,RC,C1751,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,300,
VIPERWIRE ADVANCE PERIPHERAL,5890103,CDM,278,RC,C1769,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,300,
INCISION AND REMOVAL FOREIGN BODY SUBCUT,6000103,CDM,521,RC,10120,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,718.61,
EXCISION MALG LESION OVER 4 CM,6000129,CDM,521,RC,11606,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,2843.72,
REPAIR NECK HAND FEET GENIT 2.5CM OR LES,6000143,CDM,521,RC,12041,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,551.37,
REPAIR SCALP  ARM  OR LEG 2.6 TO 7.5 CM,6000145,CDM,521,RC,13121,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,1365.74,
DEPO-PROVERA 150MG/1ML,6000329,CDM,636,RC,J1050,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,300,
INCISION AND REMOVAL FOREIGN BODY SUBCUT,6100045,CDM,521,RC,10120,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,718.61,
EXCISION MALG LESION OVER 4 CM,6100065,CDM,521,RC,11606,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,2843.72,
REPAIR NECK HAND FEET GENIT 2.5CM OR LES,6100073,CDM,521,RC,12041,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,551.37,
REPAIR SCALP  ARM  OR LEG 2.6 TO 7.5 CM,6100075,CDM,521,RC,13121,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,1365.74,
TREATMENT OF URETHRA LESION,6100107,CDM,521,RC,53260,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3367.98,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3367.98,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3367.98,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4736.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,4736.99,
INCISION AND DRAINAGE OF VULVA ABSCESS,6100109,CDM,521,RC,56405,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
DRAINAGE OF GLAND ABCESS,6100110,CDM,521,RC,56420,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
SURGERY FOR VULA LESION,6100111,CDM,521,RC,56440,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,4178.79,
BIOPSY OF VAG W/SCOPE,6100124,CDM,521,RC,57421,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1039.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,974.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,1039.68,
BX/CURETT OF CERVIX W/SCOPE,6100126,CDM,521,RC,57454,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
BIOPSY OF CERVIX W/SCOPE,6100127,CDM,521,RC,57455,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
BIOPSY OF CERVIX W/SCOPE  LE,6100129,CDM,521,RC,57460,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,4178.79,
CONIZATION OF CERVIX W/SCOPE,6100130,CDM,521,RC,57461,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,4178.79,
CRYOCAUTERY OF CERVIX,6100132,CDM,521,RC,57511,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
D&C OF CERVICAL STUMP,6100137,CDM,521,RC,57558,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,4178.79,
DILATION AND CURETTAGE,6100141,CDM,521,RC,58120,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,4178.79,
INSERT INTRAUTERINE DEVICE,6100149,CDM,521,RC,58300,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
REMOVAL OF INRAUTERINE DEVICE,6100150,CDM,521,RC,58301,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
D & C POST DELIVERY,6100163,CDM,521,RC,59160,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,4178.79,
CRITICAL CARE 1HR,6100352,CDM,521,RC,99291,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1225.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1225.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1225.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,662.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,662.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1134.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1063.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,1225.38,
CIRCUMCISION W/PLASTIBELL (MODIFIER 52),6100500,CDM,521,RC,54150,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,3748.83,
"TX METACARPAL FX, SINGLE, W/O MANIP",6100543,CDM,521,RC,26600,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,326.11,
CL-DEPO-PROVERA 150MG/1ML,6100680,CDM,636,RC,J1050,HCPCS,both,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,300,
ANAL UNLISTED PROCEDURE,6200056,CDM,360,RC,46999,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,1228.22,
TRIM SKIN LESION,6200305,CDM,360,RC,11055,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,266.88,
BREAST BIOPSY,6200325,CDM,510,RC,19100,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,2216.25,
DEBRIDEMENT OF SKINUP TO 10% OFBODY,6200331,CDM,510,RC,11000,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,1365.74,
PICC LINE KIT,6200437,CDM,360,RC,C1751,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
REMOVAL INTRAUTERINE DEVICE,6200504,CDM,360,RC,58301,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,451.36,
EXCISION MALG LESION OVER 4 CM,6300075,CDM,521,RC,11606,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,2843.72,
REPAIR NECK HAND FEET GENIT 2.5CM OR LES,6300120,CDM,521,RC,12041,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,551.37,
REPAIR SCALP ARM OR LEG 2.6 TO 7.5 CM,6300122,CDM,972,RC,13121,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,260.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,247,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,247,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,247,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,247,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,260.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,260.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,247,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,247,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,260.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,395.2,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,247,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,345.8,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,180,395.2,
DILATION AND CURETTAGE,6300174,CDM,972,RC,58120,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,160.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,228.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,228.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,228.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,228.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,160.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,160.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,228.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,228.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,160.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,365.65,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,228.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,319.94,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,160.31,365.65,
FAMILY PSYCHOTHERAPY WITH PATIENT,6600001,CDM,914,RC,90847,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
FAMILY PSYCHOTHERAPY WITHOUT PATIENT,6600002,CDM,914,RC,90846,HCPCS,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
CRITICAL CARE LEVEL 1,7000034,CDM,982,RC,99291,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,174.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,210.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,210.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,174.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,174.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,210.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,210.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,174.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,336.05,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,210.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,294.04,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,174.18,336.05,
PR MRA ABD W CONTRAST,42100015,CDM,972,RC,C8900,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR MRA ABD W & W/O CONTRAST,42100074,CDM,972,RC,C890226,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
PR CT SINUSES WITH & WO,43110068,CDM,972,RC,7048826,HCPCS,outpatient,,,300,225,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,180,180,
NAIL REMOVAL,6900008,CDM,982,RC,11730,HCPCS,outpatient,,,301,225.75,,,,,,other,Not separately reimbursable for physician setting,59.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,52.51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,52.51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,52.51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,52.51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,59.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,59.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,52.51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,52.51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,59.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,84.02,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,52.51,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,73.51,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,52.51,180.6,
CATHETER VISTA BRITE TIP 3DRC 2SH PTFE,5890068,CDM,278,RC,C1887,HCPCS,both,,,302.4,226.8,,241.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.69,302.4,
ER STRAPPING LOW BACK,1400203,CDM,450,RC,29799,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
ER UNLISTED PROC CASTING/STRAPPING,1400214,CDM,450,RC,29799,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
HEP C RNA PCR QUAL,2800340,CDM,306,RC,87521,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,242.4,
HEP C RNA PCR QUANT W/ REFLEX TO GENOTYP,2800341,CDM,302,RC,87522,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.42,242.4,
XR COLON/SOLID COLUMN SING CONT,4000045,CDM,320,RC,74270TC,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
XR SMALL BOWEL SING CONT,4000116,CDM,320,RC,74250TC,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
XR SWALLOWING FUNCTION FLUORO,4000121,CDM,320,RC,74230TC,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
XR UPPER GI SERIES SING CONT,4000129,CDM,320,RC,74240TC,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
XR ESOPHOGRAM-DOUB CONTR,4001154,CDM,320,RC,74221TC,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
XR SMALL BOWEL DOUB CONT AF UGI,4001155,CDM,320,RC,74248TC,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
XR UGI DOUB CONT,4001156,CDM,320,RC,74246TC,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,242.4,
SIGMOIDOSCOPY WITH SUBMUCOSAL INJECTION,6200412,CDM,360,RC,45335,HCPCS,outpatient,,,303,227.25,,242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,121.93,1228.22,
"Human Papilloma 9, 2 or 3 dose schedule",6000207,CDM,636,RC,90651,HCPCS,both,,,304,228,,243.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,167.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,122.33,304,
GARDASIL 9,6100536,CDM,636,RC,90651,HCPCS,both,,,304,228,,243.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,167.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,122.33,304,
DESTRUCTION 15 OR MORE LESIONS,6000147,CDM,521,RC,17004,HCPCS,outpatient,,,306,229.5,,244.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,422.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,422.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.13,551.37,
DESTRUCTION 15 OR MORE LESIONS,6100555,CDM,521,RC,17004,HCPCS,outpatient,,,306,229.5,,244.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,422.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,422.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.13,551.37,
VENTILATOR MGMT INITIAL DAY,6200317,CDM,360,RC,94002,HCPCS,outpatient,,,306,229.5,,244.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.13,822.79,
INJ CYSTO/VCUG,4000009,CDM,360,RC,51600,HCPCS,outpatient,,,307,230.25,,245.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,139.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,139.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.54,245.6,
PUNCTURE DRAINAGE OF LESION,6200240,CDM,360,RC,10160,HCPCS,outpatient,,,307,230.25,,245.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.54,551.37,
REPLACE J-TUBE,6200278,CDM,360,RC,49451,HCPCS,outpatient,,,307,230.25,,245.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,657.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,657.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,657.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,230.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,123.54,1220.05,
ACUTE ADM/DC SAME DAY,6100331,CDM,982,RC,99236,HCPCS,outpatient,,,308,231,,,,,,other,Not separately reimbursable for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,184.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,326.32,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,285.53,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,144.11,326.32,
SCREW 5 X 42.5MM LOCKING,890154,CDM,278,RC,C1713,HCPCS,both,,,308.7,231.53,,246.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.22,869.4,
SCREW 5 X 27.5MM LOCKING,890155,CDM,278,RC,C1713,HCPCS,both,,,308.7,231.53,,246.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.22,869.4,
SCREW 5 X 30MM LOCKING,890156,CDM,278,RC,C1713,HCPCS,both,,,308.7,231.53,,246.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.22,869.4,
SCREW 5 X 40MM LOCKING,890157,CDM,278,RC,C1713,HCPCS,both,,,308.7,231.53,,246.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.22,869.4,
SCREW LOCKING 5 X 35MM,890057,CDM,278,RC,C1713,HCPCS,both,,,309,231.75,,247.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.34,869.4,
SCREW LOCKING 5 X 32.5,890050,CDM,278,RC,C1713,HCPCS,both,,,310,232.5,,248,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.74,869.4,
SCREW LOCKING 5 X 50,890055,CDM,278,RC,C1713,HCPCS,both,,,310,232.5,,248,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.74,869.4,
SCREW LOCKING 5 X 45,890056,CDM,278,RC,C1713,HCPCS,both,,,310,232.5,,248,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,124.74,869.4,
BB PATIENT PHENOTYPE,3000025,CDM,300,RC,86905,HCPCS,outpatient,,,310,232.5,,248,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,13.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,4.98,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.83,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,479.01,
BB RH PHENOTYPE,3000039,CDM,300,RC,86906,HCPCS,outpatient,,,310,232.5,,248,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,27.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,10.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,10.08,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,7.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.75,100,,,fee schedule,100% UHC fee schedule for outpatient setting,7.75,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.75,248,
REMOVAL OF IMPLANT CONTRACEPTIVE CAPSULE,6200411,CDM,360,RC,11976,HCPCS,outpatient,,,312,234,,249.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.55,959.14,
DO NOT USE,4000033,CDM,320,RC,76001TC,HCPCS,outpatient,,,313,234.75,,250.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.15,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.95,250.4,
CARE PLAN OVERSIGHT HH BILLING,6200377,CDM,510,RC,G0181,HCPCS,outpatient,,,313,234.75,,250.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,125.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.95,250.4,
SCREW 3.5 LOCKING 48MM,890144,CDM,278,RC,C1713,HCPCS,both,,,313.5,235.13,,250.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.15,869.4,
SCREW 3.5MM LOCKING 46MM,890145,CDM,278,RC,C1713,HCPCS,both,,,313.5,235.13,,250.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.15,869.4,
SCREW 3.5MM LOCKING 42MM,890146,CDM,278,RC,C1713,HCPCS,both,,,313.5,235.13,,250.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.15,869.4,
SCREW 3.5MM LOCKING 36MM,890149,CDM,278,RC,C1713,HCPCS,both,,,313.5,235.13,,250.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.15,869.4,
ESOPHAGUS ENDOSCOPY,6200106,CDM,360,RC,43200,HCPCS,outpatient,,,314,235.5,,251.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,172.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,126.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,235.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.35,1529.37,
CROUPTENT SETUP-PRODUCTIVITY,5200033,CDM,271,RC,94002,HCPCS,outpatient,,,315,236.25,,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,236.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,126.76,822.79,
EQUIPMENT SET-UP-PRODUCTIVITY,5200037,CDM,270,RC,94002,HCPCS,outpatient,,,316,237,,252.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.16,822.79,
VOLUME VENT CIRCUIT,5200079,CDM,270,RC,94002,HCPCS,outpatient,,,316,237,,252.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.16,822.79,
PSYCHOTHERAPY 45 MIN WITH PATIENT- 59,6600020,CDM,914,RC,9083459,HCPCS,outpatient,,,317,237.75,,253.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.56,253.6,
PSYCHIATRIC DIAGNOSTIC EVALUATION,6690791,CDM,900,RC,90791,HCPCS,outpatient,,,317,237.75,,253.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.65,253.6,
PSYCH DIAGNOSTIC EVAL W/MEDICAL SRVCS,6690792,CDM,900,RC,90792,HCPCS,outpatient,,,317,237.75,,253.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.65,253.6,
PSYCHOTHERAPY 45 MIN WITH PATIENT,6690834,CDM,914,RC,90834,HCPCS,outpatient,,,317,237.75,,253.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,127.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.65,253.6,
SCREW 2.7MM LOCKING 20MM,890104,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.7MM LOCKING 16MM,890105,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.7MM LOCKING 18MM,890106,CDM,270,RC,C1713,HCPCS,outpatient,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.7MM LOCKING 14MM,890107,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.7 LOCKING 12MM,890162,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.4 LOCKING 18MM,890200,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.4 LOCKING 20MM,890201,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
PLUG 2.0 LOCKING 20MM,890233,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
PLUG 2.0 LOCKING 22MM,890234,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.4 LOCKING 24MM,890235,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
SCREW 2.4 LOCKING 16MM,890236,CDM,278,RC,C1713,HCPCS,both,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.96,869.4,
ST EVAL OF SPEECH SOUND PRODUCTION,5100626,CDM,440,RC,92522GN,HCPCS,outpatient,,,318,238.5,,254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,254.4,
EXCISION BENIGN LESION 1.1 - 2.0 CM,6000122,CDM,521,RC,11402,HCPCS,outpatient,,,319,239.25,,255.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,175.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.37,959.13,
EXCISION BENIGN LESION 1.1 - 2.0 CM,6100466,CDM,521,RC,11402,HCPCS,outpatient,,,319,239.25,,255.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,175.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,239.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,128.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.37,959.13,
NM PR LUNG COMPLETE VQ,4410069,CDM,972,RC,7859826,HCPCS,outpatient,,,320,240,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,192,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,192,192,
PR ASPIRATION/INJECTION LARGE JOINT BURS,4011138,CDM,973,RC,20610,HCPCS,outpatient,,,321,240.75,,,,,,other,Not separately reimbursable for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,192.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.69,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.85,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,192.6,
US ART DOP-UNILA LOWER EXT - RIGHT,4100005,CDM,921,RC,93926TC,HCPCS,outpatient,,,321,240.75,,256.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,129.17,256.8,
SCREW 3.5MM LOCKING 12MM,890064,CDM,278,RC,C1713,HCPCS,both,,,322,241.5,,257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,161,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,129.57,869.4,
SCREW 3.5 LOCKING 18 MM T10 FULL THREAD,890074,CDM,278,RC,C1713,HCPCS,both,,,322,241.5,,257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,161,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,129.57,869.4,
SCREW 3.5 LOCKING 32MM,890148,CDM,278,RC,C1713,HCPCS,both,,,322.3,241.73,,257.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,161.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,129.69,869.4,
CT BONE DENSITY,4300072,CDM,352,RC,77078TC,HCPCS,outpatient,,,323,242.25,,258.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,161.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,129.98,650,
EXC BENIGN LESION 0.5CM OR LESS,6200108,CDM,360,RC,11440,HCPCS,outpatient,,,323,242.25,,258.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,177.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,129.98,959.13,
EVALUATION SPEECH,2800269,CDM,440,RC,92521GN,HCPCS,outpatient,,,325,243.75,,260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,260,
PR MRI ABD W/CONTRAST,4210061,CDM,972,RC,7418226,HCPCS,outpatient,,,325,243.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,195,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,195,195,
"PNEUMOVAX 23, AGES 2 >",6000341,CDM,636,RC,90732,HCPCS,both,,,325,243.75,,260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.78,325,
VENT MGMT INPAT INIT DAY,6100300,CDM,521,RC,94002,HCPCS,outpatient,,,325,243.75,,260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.78,822.79,
PNEUMOVAX 23,6100668,CDM,636,RC,90732,HCPCS,both,,,325,243.75,,260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.78,325,
THORACENTESIS W/TUBE INSERTION,6200296,CDM,360,RC,32422,HCPCS,outpatient,,,325,243.75,,260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.78,260,
INCISION & DRAINAGE PERIANAL ABSCESS SUP,6200614,CDM,360,RC,46050,HCPCS,outpatient,,,325,243.75,,260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,243.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.78,1228.22,
RHOGAM 300 MCG,3204476,CDM,636,RC,J2790,HCPCS,both,,,325.5,244.13,,260.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.98,325.5,
GARDASIL VACCINE,6100445,CDM,636,RC,90649,HCPCS,both,,,325.76,244.32,,260.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.09,325.76,
PNEUMOCOCCAL (PREVNAR 13),6000212,CDM,636,RC,90670,HCPCS,both,,,326,244.5,,260.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.18,326,
PNEUMOCOCCAL VACCINE (PREVNAR 13),6100269,CDM,636,RC,90670,HCPCS,both,,,326,244.5,,260.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.18,326,
INITIAL OBSERVATION CARE-LEVEL 1,6200017,CDM,510,RC,99218,HCPCS,outpatient,,,326,244.5,,260.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.18,260.8,
REMOVE FB OUTER EAR CANAL,6200429,CDM,510,RC,69205,HCPCS,outpatient,,,326,244.5,,260.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,244.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,131.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.18,3710.83,
CEREBRAL DEATH,5600001,CDM,740,RC,95824,HCPCS,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,142.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,714.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,669.81,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,714.47,
EEG (ADULT),5600002,CDM,740,RC,95819,HCPCS,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,413.89,
EEG (PEDIATRIC),5600003,CDM,740,RC,95819,HCPCS,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,413.89,
EEG (SPECIAL),5600004,CDM,740,RC,95819,HCPCS,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,413.89,
EEG,5600007,CDM,740,RC,95819,HCPCS,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,413.89,
EEG SLEEP ONLY A/P,5600009,CDM,740,RC,95822,HCPCS,outpatient,,,327,245.25,,261.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,131.58,413.89,
DEBRIDEMENT MUSCLE/FASCIA EACH ADDTL,400028,CDM,361,RC,11046,HCPCS,outpatient,,,329,246.75,,263.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.39,263.2,
DEBRIDEMENT SKIN/SQ TISSUE EACH ADDL,400029,CDM,361,RC,11045,HCPCS,outpatient,,,329,246.75,,263.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,263.2,
DEBRIDEMENT SKIN/TISSUE,400030,CDM,361,RC,11042,HCPCS,outpatient,,,329,246.75,,263.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.39,990.21,
DEBRIDEMENT; MUSCLE/FASCIA 1ST 20SQ CM,400031,CDM,361,RC,11043,HCPCS,outpatient,,,329,246.75,,263.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.39,1555.4,
I&D REMOVAL OF FOREIGN BODY SIMPLE,6200349,CDM,510,RC,10120,HCPCS,outpatient,,,329,246.75,,263.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.39,718.61,
SHAVE SKIN LESION >2.0CM,6200486,CDM,360,RC,11313,HCPCS,outpatient,,,329,246.75,,263.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,475.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.39,551.37,
BB BLOOD ANTIBODY ID STD PANEL,3000003,CDM,300,RC,86870,HCPCS,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,41.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,41.59,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,44.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,44.04,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.59,479.01,
XR SHUNTOGRAM,4001162,CDM,320,RC,75809TC,HCPCS,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.79,264,
I&D INFECTED PILONIDAL CYST SIMPLE,6200345,CDM,510,RC,10080,HCPCS,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.79,1845.77,
CATHETER TRAILBLAZER SUPPORT,90003030,CDM,270,RC,C1887,HCPCS,outpatient,,,330,247.5,,264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,132.79,264,
PR XR SWALLOWING FUNCTION FLUORO,4010121,CDM,972,RC,74230,HCPCS,outpatient,,,331,248.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,198.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,90.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,90.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,90.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,90.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,145.47,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,90.92,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.29,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,90.92,198.6,
EXCISION BENIGN LESION;0.6 TO 1.0 CM,6200008,CDM,982,RC,11401,HCPCS,outpatient,,,331,248.25,,,,,,other,Not separately reimbursable for physician setting,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,101.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,198.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,101.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,101.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,101.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,101.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,101.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,161.78,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,101.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,141.55,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,83.48,198.6,
INITIAL HOSPITAL CARE-LEVEL 4,6200013,CDM,510,RC,99221,HCPCS,outpatient,,,331,248.25,,264.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.19,264.8,
INITIAL INPATIENT CONSULT-LEVEL 1,6200014,CDM,510,RC,99251,HCPCS,outpatient,,,331,248.25,,264.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,133.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,133.19,264.8,
HSV 1/2 BY PCR,2800363,CDM,300,RC,87529,HCPCS,outpatient,,,332,249,,265.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,182.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,265.6,
HSV 1/2 CSF,2801442,CDM,300,RC,87529,HCPCS,outpatient,,,332,249,,265.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,182.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,249,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,265.6,
ST EVAL OF SPEECH/SOUND PRODUCT,5100533,CDM,440,RC,92523GN,HCPCS,outpatient,,,333,249.75,,266.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,266.4,
ST BEHAVIORAL & QUALITATIVE ANALYS,5100627,CDM,440,RC,92524GN,HCPCS,outpatient,,,333,249.75,,266.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,266.4,
NEW OFFICE VISIT-COMPREHENSIVE,6200022,CDM,510,RC,99205,HCPCS,outpatient,,,333,249.75,,266.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57,266.4,
NEW OFFICE VISIT-INTERMEDIATE,6200023,CDM,510,RC,99204,HCPCS,outpatient,,,333,249.75,,266.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57,266.4,
OFFICE VISIT- LVL V,6200033,CDM,510,RC,99215,HCPCS,outpatient,,,333,249.75,,266.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57,266.4,
OFFICE VISIT- LVL IV,6200034,CDM,510,RC,99214,HCPCS,outpatient,,,333,249.75,,266.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57,266.4,
EST LEVEL 4 OV,6900080,CDM,982,RC,99214,HCPCS,outpatient,,,333,249.75,,,,,,other,Not separately reimbursable for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.83,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,199.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.83,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.83,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.83,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,94.83,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,94.83,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,151.73,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,94.83,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,132.76,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.65,199.8,
EST LEVEL 5 OV,6900081,CDM,982,RC,99215,HCPCS,outpatient,,,333,249.75,,,,,,other,Not separately reimbursable for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,139.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,199.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,139.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,139.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,139.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,222.64,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,139.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,194.81,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,84.93,222.64,
NEW LEVEL 4 OV,6900075,CDM,982,RC,99204,HCPCS,outpatient,,,334,250.5,,,,,,other,Not separately reimbursable for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,129.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,200.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,129.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,129.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,129.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,129.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,129.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,207.95,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,129.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,181.96,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,96.56,207.95,
LOVENOX 100MG/1mL INJ,3200511,CDM,636,RC,J1650,HCPCS,both,,,334.5,250.88,,267.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,167.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,167.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,167.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,267.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,267.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,134.6,334.5,
SFMC ADALIMUMAB LEVEL,2800448,CDM,301,RC,80299,HCPCS,outpatient,,,335,251.25,,268,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,184.25,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,268,
REPAIR SUPERFICIAL WOUND,6200274,CDM,360,RC,12001,HCPCS,outpatient,,,335,251.25,,268,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,134.8,375.41,
REPOSITION VENOUS CATHETHER,6200506,CDM,360,RC,36597,HCPCS,outpatient,,,335,251.25,,268,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,134.8,2198.94,
BENTYL 10MG/5ML ELIXIR,6000289,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
IV INFUSION INITIAL HR -59 MOD,1400119,CDM,260,RC,9636559,HCPCS,outpatient,,,336,252,,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.21,268.8,
IV PUSH-INITIAL / MODIFIER 59,1400120,CDM,260,RC,9637459,HCPCS,outpatient,,,336,252,,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.21,268.8,
INJECTION INTRAVENOUS,1400222,CDM,761,RC,96374,HCPCS,outpatient,,,336,252,,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,122.66,305.27,
INJECTION INTRAVENOUS,1400224,CDM,940,RC,96374,HCPCS,outpatient,,,336,252,,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,122.66,305.27,
IV DRUG INFUSION INITIAL HR,1400233,CDM,260,RC,96365,HCPCS,outpatient,,,336,252,,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,122.66,305.27,
FINE NEEDLE ASPIRATION ORBITAL CONTENTS,6200170,CDM,360,RC,67415,HCPCS,outpatient,,,336,252,,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3416.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3416.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3416.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1952.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,184.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1823.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1823.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1823.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1952.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1952.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3124.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1952.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.21,3416.5,
US PELVIC WALL BUTTOCK PERINEUM ST,4001150,CDM,402,RC,76857TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US ABD LIMITED,4100001,CDM,402,RC,76705TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US AORTA COMPLETE,4100002,CDM,402,RC,76770TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US SOFT TISSUES OF NECK,4100008,CDM,402,RC,76536TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US CHEST,4100012,CDM,402,RC,76604TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US GALLBLADDER,4100015,CDM,402,RC,76705TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US LIVER,4100019,CDM,402,RC,76705TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
DO NOT USE,4100020,CDM,402,RC,76882,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,22.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,98.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,22.25,269.6,
US OB > OR = 14 WEEKS,4100021,CDM,402,RC,76805TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US OB EACH ADDITONAL GESTATIONAL,4100022,CDM,402,RC,76810TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US PANCREAS,4100023,CDM,402,RC,76705TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US PELVIS NON OB COMPLETE,4100024,CDM,402,RC,76856TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US RENAL COMPLETE,4100025,CDM,402,RC,76770TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US RETROPERITENEAL SP COMPLETE,4100026,CDM,402,RC,76770TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US SCROTUM/TESTICULAR,4100027,CDM,402,RC,76870TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US SOFT TISSUE HEAD AND NECK,4100028,CDM,402,RC,76536TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US SPLEEN,4100029,CDM,402,RC,76705TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US THYROID HEAD/NECK,4100030,CDM,402,RC,76536TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US TRANSRECTAL,4100031,CDM,402,RC,76872TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US TRANSVAG PELVIS,4100032,CDM,402,RC,76830TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US UPPER ABDOMEN COMPLETE,4100033,CDM,402,RC,76700TC,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US NON VASCULAR EXTREMITY - LIMITED - LT,4100046,CDM,402,RC,76882LT,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
US NON VASCULAR EXTREMITY - LIMITED RT,4100050,CDM,402,RC,76882RT,HCPCS,outpatient,,,337,252.75,,269.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.61,269.6,
"REMOVAL WITH REINSERTION, NON-BIODEGRADE",6900236,CDM,982,RC,11983,HCPCS,outpatient,,,337,252.75,,,,,,other,Not separately reimbursable for physician setting,149.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.54,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,202.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.54,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.54,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.54,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,149.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.54,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,102.54,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,149.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,164.06,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,102.54,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,143.56,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,102.54,202.2,
THYROGLOBULIN MASS SPECTROMETRY CHARGE,2800098,CDM,301,RC,84432,HCPCS,outpatient,,,338,253.5,,270.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,56.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.02,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,185.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,20.88,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.06,100,,,fee schedule,100% UHC fee schedule for outpatient setting,16.06,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,25.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.02,270.4,
REMOVE DRUG IMPLANT DEVICE,6200568,CDM,360,RC,11982,HCPCS,outpatient,,,338,253.5,,270.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,136.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,253.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.34,558.02,
EXPAREL 133MG/10ML,3204521,CDM,636,RC,C9290,HCPCS,both,,,340,255,,272,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,136.82,340,
US GUIDED NEEDLE PLACEMENT/SURGICAL,4100018,CDM,402,RC,76942TC,HCPCS,outpatient,,,340,255,,272,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,136.82,272,
SFMC HCV GENOTYPE,2800322,CDM,306,RC,87902,HCPCS,outpatient,,,341,255.75,,272.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,187.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,411.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.72,909.01,
HEPATITIS C PCR QUANT REFLEX ORDER ONLY,2800345,CDM,306,RC,87522,HCPCS,outpatient,,,341,255.75,,272.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,187.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.42,272.8,
PERQ DEVICE BREAST 1ST IMAGE,6200514,CDM,360,RC,19281,HCPCS,outpatient,,,341,255.75,,272.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,137.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2077.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,137.22,2216.25,
RADIATION TREATMENT  SINGLE AREA,4000020,CDM,333,RC,77402,HCPCS,outpatient,,,342,256.5,,273.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,115.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,115.99,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,113.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,188.1,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,105.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,137.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,137.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,256.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,113.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.55,273.6,
CONT OVERNIGHT O2 SAT MONITOR,1400502,CDM,460,RC,94762,HCPCS,outpatient,,,345,258.75,,276,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,276,
SFMC CARBAPENEMASE TEST,2801353,CDM,306,RC,87186,HCPCS,outpatient,,,345,258.75,,276,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.54,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,189.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,11.25,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.32,276,
XR FLUORO FOR SPINE INJECTION,4000058,CDM,320,RC,77003,HCPCS,outpatient,,,345,258.75,,276,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,172.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,276,
PACEMAKER FLOURO,5800109,CDM,320,RC,71090TC,HCPCS,outpatient,,,345,258.75,,276,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,172.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,138.83,276,
SCREW 4.0 CANN 48MM,890124,CDM,278,RC,C1713,HCPCS,both,,,345.6,259.2,,276.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,172.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.07,869.4,
SCREW 4.0 CANN 50MM,890224,CDM,278,RC,C1713,HCPCS,both,,,345.6,259.2,,276.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,172.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.07,869.4,
SCREW 4.0 CANN 46MM,890225,CDM,278,RC,C1713,HCPCS,both,,,345.6,259.2,,276.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,172.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.07,869.4,
MONSEL'S SOLUTION,6000337,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
I&D OF A THROMBOSED HEMORRHOID,6200045,CDM,360,RC,46083,HCPCS,outpatient,,,346,259.5,,276.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,139.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,259.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.23,664.5,
INDIVIDUAL THERAPY,6600009,CDM,915,RC,90806,HCPCS,outpatient,,,347,260.25,,277.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,139.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.63,277.6,
WELCOME TO MCARE EXAM,6900100,CDM,982,RC,G0438,HCPCS,outpatient,,,347,260.25,,,,,,other,Not separately reimbursable for physician setting,118.73,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,158.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,208.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,158.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,158.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,158.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,118.73,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,118.73,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,158.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,158.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,118.73,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,253.3,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,158.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,221.63,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,118.73,253.3,
ER FB-CORNEA WITH SLIT LAMP,1400087,CDM,450,RC,65222,HCPCS,outpatient,,,348,261,,278.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,278.4,
ER STRAPPING ANKLE/FOOT,1400197,CDM,450,RC,29540,HCPCS,outpatient,,,348,261,,278.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,278.4,
ER STRAPPING ANKLE/FOOT,1400198,CDM,450,RC,29540,HCPCS,outpatient,,,348,261,,278.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,278.4,
ER STRAPPING THORAX,1400204,CDM,450,RC,29200,HCPCS,outpatient,,,348,261,,278.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,278.4,
XR CHEST FLUOROSCOPY IVIEW CXR,4000039,CDM,324,RC,71023TC,HCPCS,outpatient,,,348,261,,278.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.04,278.4,
XR CHEST FLUOROSCOPY IVIEW CXR,4100039,CDM,972,RC,71023TC,HCPCS,outpatient,,,348,261,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,208.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,208.8,208.8,
PR XR CHEST FLUOROSCOPY IVIEW CXR,4110039,CDM,972,RC,7102326,HCPCS,outpatient,,,348,261,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,208.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,208.8,208.8,
PERCUT BX LUNG/MEDIASTINUM,6200522,CDM,360,RC,32405,HCPCS,outpatient,,,348,261,,278.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.04,278.4,
QUANTIFERON GOLD TB,2800523,CDM,305,RC,86480,HCPCS,outpatient,,,349,261.75,,279.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,184.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,184.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,184.69,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,30.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,191.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,80.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,80.57,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,61.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.98,100,,,fee schedule,100% UHC fee schedule for outpatient setting,61.98,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,99.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,92.97,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.99,279.2,
SFMC T SPOT FOR TB,2801347,CDM,305,RC,86481,HCPCS,outpatient,,,349,261.75,,279.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,186.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,186.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,186.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,50,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,191.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,130,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,130,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,130,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,130,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,130,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,130,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,87.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,87.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,100,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,100,,,fee schedule,100% UHC fee schedule for outpatient setting,87.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,160,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,100,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50,279.2,
MM MAMMOGRAM DIAGNOSTIC UNILATERAL LT*,4000207,CDM,401,RC,77065,HCPCS,outpatient,,,349,261.75,,279.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.86,279.2,
MM MAMMOGRAM DIAGNOSTIC UNILATERAL RT *,4001147,CDM,401,RC,77065,HCPCS,outpatient,,,349,261.75,,279.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,127.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,140.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,124.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,77.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,279.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.86,279.2,
REMOVAL VAGINAL FOREIGN BODY,600161,CDM,969,RC,57415,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,272.56,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,238.49,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,103.19,272.56,
HAND CASTING,1400284,CDM,450,RC,29085,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,280,
XR UGI WITH SBFT,4000128,CDM,320,RC,74245TC,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
SCREENING,4000169,CDM,403,RC,G0202TC,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
MM MAMMOGRAM SCREENING UNILATERAL LEFT*,4000205,CDM,403,RC,77067,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.31,280,
MM MAMMOGRAM SCREENING UNILATERAL RIGHT*,4000209,CDM,403,RC,77067,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.31,280,
MM MAMMOGRAM SCREENING BILATERAL*,4000210,CDM,403,RC,77067,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,143.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.7,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,82.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,123.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.31,280,
PR US THORA-RADIOLOGY,4010137,CDM,972,RC,32555,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,170.62,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.3,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,416.98,
RAPID COVID ANTIGEN SCC,6000500,CDM,300,RC,87426,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,17.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.99,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.66,56.52,
FLU VACCINE ADM M/C SCC,6080008,CDM,771,RC,G0008,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,62.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,39.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,36.54,62.61,
PR MRI UPPER EXT JOINT W&W/O CONTRAST LT,4200052,CDM,610,RC,7322326LT,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,1150,
PR MRI ABD W/WO CONTRAST,4210008,CDM,972,RC,7418326,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
WIC 17 PKU LEAD,6100003,CDM,510,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
PR MRI UPPER EXT JOINT W&W/O CONTRAST RT,4210013,CDM,972,RC,7322326RT,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
BENTYL 10MG/5ML ELIXIR,6100005,CDM,250,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
PR MRI CER/SPINE W/WO/CONTRAST,4210019,CDM,972,RC,7215626,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR MRI ORBIT FACE W/WO CONTRAST,4210034,CDM,972,RC,7054326,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR MRI UPPER EXT JOINT W&W/O CONTRAST LT,4210052,CDM,972,RC,7322326LT,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR MRI LOW EXT NON JOINT W/WO RT,4210063,CDM,972,RC,73720RT26,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR MRI LOW EXT NON JOINT W/WO LT,4210064,CDM,972,RC,7372026LT,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR MRA ABD W/O CONTRAST,4210073,CDM,972,RC,C8901,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR MRI UPPER EXT JOINT W&W/O CONTRAST LT,4210081,CDM,972,RC,7322326LT,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CT ABD AND PELVIS WO CONTRAST,4310002,CDM,972,RC,7417626,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CT BRAIN WITH & WO,4310009,CDM,972,RC,7047026,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CTA HEAD,4310048,CDM,972,RC,7049626,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CTA NECK,4310049,CDM,972,RC,7049826,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CTA UPPER EXTREMITY RT,4310050,CDM,972,RC,7320626RT,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CTA UPPER EXTREMITY LT,4310067,CDM,972,RC,7320626LT,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CTA LOWER EXTREMITY UNILATERAL W/WO,4310069,CDM,972,RC,7370626,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
PR CTA UPPER EXTREMITY UNILATERAL  W/WO,4311068,CDM,972,RC,7320626,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,210,210,
TRIM SKIN LESION,6000108,CDM,521,RC,11055,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
"REPAIR, INTERMEDIATE 2.6 CM TO 7.5 CM",6000141,CDM,521,RC,12032,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,718.61,
REPAIR NECK HAND FEET GENIT 2.6 TO 7.5CM,6000144,CDM,521,RC,12042,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,718.61,
REMOVAL OF THROMBOSIS,6000159,CDM,521,RC,46255,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,4526.47,
REMOVAL VAGINAL FOREIGN BODY,6000161,CDM,969,RC,57415,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,272.56,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,238.49,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,103.19,272.56,
CYTOPATH C/V MANUAL SCC,6000196,CDM,521,RC,88150,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.65,280,
TRIM SKIN LESION,6100050,CDM,521,RC,11055,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
REPAIR NECK HAND FEET GENIT 2.6 TO 7.5CM,6100074,CDM,521,RC,12042,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,718.61,
REMOVE ABDOMINAL WALL,6100081,CDM,521,RC,22900,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,3817.9,
REMOVAL OF THROMBOSIS,6100098,CDM,521,RC,46255,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,4526.47,
ASPIRATION OF OVARY,6100102,CDM,521,RC,49322,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,7703.27,
PARTIAL REMOVAL OF VULVA,6100115,CDM,521,RC,56620,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,5080.81,
KIDMED NURSE SCREENING,6100035,CDM,510,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
INTERPERIODIC SCREENING 0-12 YRS,6100036,CDM,250,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
VISION SCREENING,6100037,CDM,510,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
HEARING SCREENING,6100038,CDM,510,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
REMOVAL OF VAGINA GLAND LESION,6100116,CDM,521,RC,56740,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,4178.79,
REMOVAL VAGINAL FOREIGN BODY,6100122,CDM,969,RC,57415,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,103.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,272.56,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,170.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,238.49,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,103.19,272.56,
RURAL HEALTH OV,6100041,CDM,521,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
SPINAL FLUID TAP DIAGNOSIC,6100164,CDM,521,RC,62270,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,952.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,952.29,
CYTOPATH C/V MANUAL,6100237,CDM,521,RC,88150,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,44.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.5,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.12,100,,,fee schedule,100% UHC fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.65,280,
"REPAIR, INTERMEDIATE 2.6 CM TO 7.5 CM",6112032,CDM,521,RC,12032,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,718.61,
I AND D TO VULVA,6200185,CDM,360,RC,56405,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,451.36,
PR US THORACENTESIS,6210469,CDM,972,RC,32555,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,416.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,170.62,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,106.64,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.3,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,106.64,416.98,
REPAIR NECK HAND FEET GENIT 2.6 TO 7.5CM,6300121,CDM,521,RC,12042,HCPCS,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,718.61,
SAME DAY ADMIT/D/C-55 MIN BEDSIDE,7000010,CDM,982,RC,99236,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,144.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,326.32,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,203.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,285.53,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,144.11,326.32,
SWING BED DISCHARGE-LESS THAN 30 MINS,7000032,CDM,982,RC,99315,HCPCS,outpatient,,,350,262.5,,,,,,other,Not separately reimbursable for physician setting,40.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,40.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,40.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,78.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,78.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,40.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,126,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,78.75,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,110.25,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,40.15,210,
INFLUENZA A&B RAPID MOLECULAR RMC,2800381,CDM,302,RC,87502,HCPCS,outpatient,,,351,263.25,,280.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,255.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,255.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,255.43,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,47.9,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,193.05,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,124.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,124.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,124.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,124.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,124.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,124.54,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,280.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,95.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,95.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,95.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,263.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.8,100,,,fee schedule,100% UHC fee schedule for outpatient setting,95.8,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,153.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,95.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,280.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.9,280.8,
PELVIC EXAM UNDER ANESTHESIA,6200555,CDM,510,RC,57410,HCPCS,outpatient,,,352,264,,281.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,141.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,141.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,264,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,141.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,281.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,141.64,4178.79,
EXC BENIGN LESION 0.6CM TO 1.0CM,6200109,CDM,360,RC,11421,HCPCS,outpatient,,,353,264.75,,282.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,282.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,264.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,282.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.05,1316.03,
SCREW 3.5MM LOCKING 14MM T10 FULL THREAD,890063,CDM,278,RC,C1713,HCPCS,both,,,354,265.5,,283.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.45,869.4,
SCREW 3.5MM LOCKING 16MM T10 FULL THREAD,890065,CDM,278,RC,C1713,HCPCS,both,,,354,265.5,,283.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.45,869.4,
SCREW 3.5 LOCKING 30MM,890207,CDM,278,RC,C1713,HCPCS,both,,,354,265.5,,283.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.45,869.4,
SCREW 3.5 LOCKING 34MM,890208,CDM,278,RC,C1713,HCPCS,both,,,354,265.5,,283.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.45,869.4,
SCREW 3.5 LOCKING 70MM,890209,CDM,278,RC,C1713,HCPCS,both,,,354,265.5,,283.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.45,869.4,
SCREW 3.5 LOCKING 10MM,890223,CDM,278,RC,C1713,HCPCS,both,,,354,265.5,,283.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.45,869.4,
COLPOSCOPY OF THE VULVA,6900230,CDM,982,RC,56820,HCPCS,outpatient,,,354,265.5,,,,,,other,Not separately reimbursable for physician setting,71.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,212.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,83.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.12,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,133.41,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,83.38,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.73,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.12,212.4,
INSERTION OF PESSARY OR OTHER INTRAVAGIN,6900232,CDM,982,RC,57160,HCPCS,outpatient,,,354,265.5,,,,,,other,Not separately reimbursable for physician setting,48.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,212.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,45.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,45.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,48.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,48.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,45.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,45.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,48.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,73.07,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,45.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,63.94,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,45.67,212.4,
EXCISION-LESION,6100061,CDM,521,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
ENDOMETRIAL BX IN CONJUNCT W/COLPOSCOPY,6900258,CDM,982,RC,58110,HCPCS,outpatient,,,354,265.5,,,,,,other,Not separately reimbursable for physician setting,31.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,39.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,212.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,39.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,39.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,39.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,31.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,31.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,39.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,39.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,31.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,63.44,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,39.65,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,55.51,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,31.99,212.4,
GLUCAGON INJ 1MG,3200341,CDM,636,RC,J1610,HCPCS,both,,,355,266.25,,284,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,266.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,142.85,355,
HIV-2 DNA/RNA BY PCR,2801188,CDM,301,RC,87538,HCPCS,outpatient,,,356,267,,284.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,195.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,284.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,284.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,267,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,284.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,284.8,
ENDOMETRIAL BIOPSY W/WO ENDOCERVICAL SAM,6900227,CDM,982,RC,58100,HCPCS,outpatient,,,356,267,,,,,,other,Not separately reimbursable for physician setting,70.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,213.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,70.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,100.18,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,62.61,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,87.65,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.61,213.6,
COSYNTROPIN INJECTION PWD FOR SOLN .25MG,3203883,CDM,636,RC,J0834,HCPCS,both,,,356.09,267.07,,284.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,143.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,267.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,284.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,143.29,356.09,
CHROMOSOME ANALYSIS TISSUE CULTURE,2800163,CDM,311,RC,88230,HCPCS,outpatient,,,357,267.75,,285.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,271.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.09,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,58.24,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,196.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,151.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,151.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,151.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,151.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,151.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,151.44,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,86.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,86.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.49,100,,,fee schedule,100% UHC fee schedule for outpatient setting,86.97,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,186.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.24,285.6,
REMOVE EYELID FOREIGN BODY,6200257,CDM,360,RC,67938,HCPCS,outpatient,,,359,269.25,,287.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,244.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,197.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,228.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,228.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,244.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,269.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,391.21,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,244.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,366.76,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,144.46,391.21,
DO NOT USE,421007,CDM,972,RC,7054926,HCPCS,outpatient,,,360,270,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,216,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,216,216,
CHEMO ADMIN INTRAVINFUSION ADDITIONAL HR,1696415,CDM,335,RC,96415,HCPCS,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,97.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,97.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.19,288,
GONADOTROPIN RELEASING HORMONE,2801097,CDM,301,RC,83727,HCPCS,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,60.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,60.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.59,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,198,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.35,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.78,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.59,288,
SFMC CHG ONLY PLA2R,2801391,CDM,300,RC,83520,HCPCS,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,198,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,288,
DIFLUCAN 400MG IV PREMIX,3200242,CDM,636,RC,J1450,HCPCS,both,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,144.86,360,
PR MRI BRAIN W/WO CONTRAST,4010260,CDM,972,RC,7055326,HCPCS,outpatient,,,360,270,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,216,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,216,216,
PR MRA HEAD W/WO CONTRAST,4210004,CDM,972,RC,7054626,HCPCS,outpatient,,,360,270,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,216,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,216,216,
PR MRI BRAIN W/AND/WO CONTRAST,4210015,CDM,972,RC,7055326,HCPCS,outpatient,,,360,270,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,216,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,216,216,
PR MRA PELVIS W CONTRAST,4210072,CDM,972,RC,7219826,HCPCS,outpatient,,,360,270,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,216,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,216,216,
PR MRA LOWER EXT W & W/O CONTRAST,4210078,CDM,972,RC,C8914,HCPCS,outpatient,,,360,270,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,216,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,216,216,
PR CT ABD AND PELVIS WITH CONTRAST,4310003,CDM,972,RC,7417726,HCPCS,outpatient,,,360,270,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,216,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,216,216,
NM I 131 SODIUM IODIDE CAPSULE,4400034,CDM,344,RC,A9517,HCPCS,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.73,288,
PFT  BASIC*,5200059,CDM,460,RC,94010,HCPCS,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.43,288,
PEAK FLOW TREATMENT,5200062,CDM,460,RC,94150,HCPCS,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.81,288,
ER VISIT LEVEL V,6100351,CDM,521,RC,9928525,HCPCS,outpatient,,,360,270,,288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,144.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,144.86,288,
PROQUAD VACCINE,6100443,CDM,636,RC,90710,HCPCS,both,,,360.7,270.53,,288.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,145.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.15,360.7,
"ANORECTAL EXAM,SURG,REQ ANESTHESIA,DIAG",6200057,CDM,360,RC,45990,HCPCS,outpatient,,,361,270.75,,288.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.27,3797.53,
ADDITIONAL LESION SEPERATELY IDENTIFIED,6200481,CDM,360,RC,19126,HCPCS,outpatient,,,361,270.75,,288.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.27,3684.92,
SCREW 2.7 LOCKING 18MM,890284,CDM,278,RC,C1713,HCPCS,both,,,363.56,272.67,,290.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.3,869.4,
SCREW 2.7 LOCKING 16MM,890285,CDM,278,RC,C1713,HCPCS,both,,,363.56,272.67,,290.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.96,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,290.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.3,869.4,
SIGMOIDOSCOPY AND POLYPECTOMY,6200395,CDM,360,RC,45333,HCPCS,outpatient,,,364,273,,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1510.22,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1510.22,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1510.22,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,273,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.47,1510.22,
DES-Y-CARBOXY PROTHROMBIN (DCP),2800699,CDM,301,RC,83951,HCPCS,outpatient,,,365,273.75,,292,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,200.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,200.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,200.58,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,32.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,200.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,83.73,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,64.41,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,103.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,64.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,96.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.2,292,
PR CT CTA CHEST W/WO,4310017,CDM,972,RC,7127526,HCPCS,outpatient,,,365,273.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,219,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,219,219,
EEG 41-60 MINTUES,5600005,CDM,740,RC,95812,HCPCS,outpatient,,,365,273.75,,292,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,200.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.88,413.89,
NEEDLE BIOPSY LIVER W/OTHER MAJOR PROC,6200613,CDM,360,RC,47001,HCPCS,outpatient,,,365,273.75,,292,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.04,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,241.04,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,241.04,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.88,292,
ZOSTAVAX .65 ML,6000234,CDM,636,RC,90736,HCPCS,both,,,366,274.5,,292.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.28,366,
ZOSTAVAX .65 ML,6100304,CDM,636,RC,90736,HCPCS,both,,,366,274.5,,292.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,183,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.28,366,
EXC BENIGN LESION 1.1CM TO 2.0CM,6200111,CDM,360,RC,11402,HCPCS,outpatient,,,366,274.5,,292.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.28,959.13,
CHEMICAL CAUTERIZATION,6200560,CDM,360,RC,17250,HCPCS,outpatient,,,366,274.5,,292.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,274.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.28,292.8,
VISTASEQ 10,2801110,CDM,301,RC,81403,HCPCS,outpatient,,,370,277.5,,296,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,395.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,395.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,395.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,92.6,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,203.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,240.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,240.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,240.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,240.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,240.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,240.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,296.32,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,185.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,92.6,395.04,
EXCAVATION HEMORRHOIDS,6100099,CDM,521,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
MYNXGRIP VASCULAR 5FR CLOSURE DEVICE,90006819,CDM,278,RC,C1760,HCPCS,both,,,370,277.5,,296,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,148.89,370,
PR XR UGI DOUB CONT,4011156,CDM,972,RC,74246,HCPCS,outpatient,,,371,278.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,88.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,222.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,88.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,88.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,88.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,88.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,88.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,141.68,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,88.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,123.97,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,88.55,222.6,
INTUBATION ENDOTRACHEAL EMERGENCYPROC,6200199,CDM,360,RC,31500,HCPCS,outpatient,,,371,278.25,,296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,204.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,149.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,149.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,296.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,149.29,466.07,
PIN DRILL 3.7 MM,890288,CDM,278,RC,C1713,HCPCS,both,,,372,279,,297.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,149.69,869.4,
XR ESOPHOGRAM,4000188,CDM,320,RC,74220TC,HCPCS,outpatient,,,372,279,,297.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,186,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.6,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,149.69,297.6,
PROCTOSIGMOIDOSCOPY ABLATION,6200237,CDM,360,RC,45320,HCPCS,outpatient,,,373,279.75,,298.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3808.54,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3808.54,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3808.54,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,205.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.1,3808.54,
THIOPURINE METABOLITES,2801415,CDM,301,RC,80299,HCPCS,outpatient,,,374,280.5,,299.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.36,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.32,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,205.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,24.23,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,280.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.32,299.2,
DEBRIDEMENT OF NAILS,1400266,CDM,450,RC,11720,HCPCS,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,142.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,142.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.57,300,
LOVENOX 120MG INJ,3200512,CDM,636,RC,J1650,HCPCS,both,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,375,
DO NOT USE,4000086,CDM,401,RC,G0204TC,HCPCS,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
PR CT CTA ABD W/WO & IMAGE PROCESSING,4310016,CDM,972,RC,7417526,HCPCS,outpatient,,,375,281.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,225,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,225,225,
PR CTA LOWER EXTREMITY,4310024,CDM,972,RC,7370626,HCPCS,outpatient,,,375,281.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,225,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,225,225,
EXCISION BENIGN LESION 3.1CM TO 4.0CM,6000123,CDM,521,RC,11404,HCPCS,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,2843.72,
EXCISION BENIGN LESION 3.1CM TO 4.0CM,6100463,CDM,521,RC,11404,HCPCS,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,2843.72,
CPT CHG ONLY AFB ID BY SEQUENCING,2800883,CDM,306,RC,87153,HCPCS,outpatient,,,377,282.75,,301.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.36,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,289.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,289.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,289.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.68,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,207.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,149.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,149.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,149.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,149.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,149.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,149.97,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,115.36,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,115.36,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,115.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,282.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.36,100,,,fee schedule,100% UHC fee schedule for outpatient setting,115.36,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,184.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,115.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.68,301.6,
AMPHETAMINES CONFIRMATION,2800060,CDM,301,RC,80324,HCPCS,outpatient,,,378,283.5,,302.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.44,302.4,
PR CT CTA PELVIS W/WO & IMAGE PROCESSING,4310018,CDM,972,RC,7219126,HCPCS,outpatient,,,378,283.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,226.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,226.8,226.8,
DO NOT USE,4000194,CDM,320,RC,74327TC,HCPCS,outpatient,,,379,284.25,,303.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,189.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.45,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.51,303.2,
I&D OF HEMATOMASIMPLE,6200348,CDM,510,RC,10140,HCPCS,outpatient,,,379,284.25,,303.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,208.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,284.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,152.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.51,3001.14,
CATHETER EVERCROSS DILATATION,5890143,CDM,278,RC,C1725,HCPCS,both,,,380,285,,304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.91,380,
"REMOVAL FOREIGN BODY, INTRANASAL",6000156,CDM,521,RC,30300,HCPCS,outpatient,,,380,285,,304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,209,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,304,
Human Papillo vacc Quad 3 dose,6000206,CDM,636,RC,90649,HCPCS,both,,,380,285,,304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.91,380,
GARDASIL VACC .5 ML,6100263,CDM,636,RC,90649,HCPCS,both,,,380,285,,304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.91,380,
"REMOVAL FOREIGN BODY, INTRANASAL",6100554,CDM,521,RC,30300,HCPCS,outpatient,,,380,285,,304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,209,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,304,
GARDASIL VACC .5 ML,6900174,CDM,982,RC,90649,HCPCS,outpatient,,,380,285,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,228,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,228,228,
CATHETER DILATATION EV3 AB35W07040135,90001571,CDM,278,RC,C1725,HCPCS,both,,,380,285,,304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,152.91,380,
SCREW LOCKING 5 X 52.5,890292,CDM,278,RC,C1713,HCPCS,both,,,380.82,285.62,,304.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,153.24,869.4,
DRAINAGE EXTERNAL EAR ABSCESS SIMPLE,6200091,CDM,360,RC,69000,HCPCS,outpatient,,,381,285.75,,304.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,209.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,285.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,153.31,959.13,
XR SWALLOWING FUNCTION FLUORO,4000193,CDM,320,RC,74230TC,HCPCS,outpatient,,,382,286.5,,305.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.1,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,153.72,305.6,
FNA ASPIRATION BX CT GUIDANCE 1ST LESION,6200619,CDM,360,RC,10009,HCPCS,outpatient,,,383,287.25,,306.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,154.12,1845.77,
COLPOSCOPY OF VULVA W/BIOPSY,6100706,CDM,521,RC,56821,HCPCS,outpatient,,,386,289.5,,308.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,289.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,155.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.33,451.36,
RECLAST INJ. 5MG,3200735,CDM,636,RC,J3489,HCPCS,both,,,386.4,289.8,,309.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,155.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.49,386.4,
SPUTUM COLLECTION,5200072,CDM,309,RC,89220,HCPCS,outpatient,,,389,291.75,,311.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.99,311.2,
EMERGENCY ROOM VISIT LEVEL 4,6200007,CDM,510,RC,9928425,HCPCS,outpatient,,,389,291.75,,311.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.53,311.2,
EXCISION OF PERIANAL SKIN TAG,6200384,CDM,360,RC,46220,HCPCS,outpatient,,,389,291.75,,311.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,291.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.53,3429.47,
BB BLOOD-PACKED CELLS,3000011,CDM,381,RC,P9016BL,HCPCS,outpatient,,,390,292.5,,312,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.94,312,
Pneumonia Vaccine (PREVNAR 13),3201058,CDM,636,RC,90670,HCPCS,both,,,390,292.5,,312,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.94,390,
US ART DOP-UNILA UPPER EXT,4100006,CDM,921,RC,93931TC,HCPCS,outpatient,,,392,294,,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,157.74,313.6,
US ARTERIAL DOPPLER UPPER EXT - LEFT,4100048,CDM,921,RC,93931TC,HCPCS,outpatient,,,392,294,,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,157.74,313.6,
US ARTERIAL DOPPLER UPPER EXT - RIGHT,4100049,CDM,921,RC,93931TC,HCPCS,outpatient,,,392,294,,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,157.74,313.6,
PR PUNCT ASPIRATION ABCESS,4110066,CDM,972,RC,10160,HCPCS,outpatient,,,393,294.75,,,,,,other,Not separately reimbursable for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,235.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,147.65,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,129.19,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,74.76,235.8,
NM VENOGRAM W/ISOTOPE BILATERAL,4400063,CDM,341,RC,78458TC,HCPCS,outpatient,,,393,294.75,,314.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.15,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,158.14,314.4,
ST EVAL OF SPEECH FLUENCY,5100625,CDM,440,RC,92521GN,HCPCS,outpatient,,,393,294.75,,314.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,314.4,
PUNCH BIOPSY OF SKIN SINGLE LESION,6100714,CDM,361,RC,11104,HCPCS,outpatient,,,393,294.75,,314.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,158.14,562.17,
BIOPSY OF SKIN SINGLE LESION,6200320,CDM,361,RC,11100,HCPCS,outpatient,,,393,294.75,,314.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,158.14,314.4,
PUNCH BIOPSY OF SKIN SINGLE LESION,6200600,CDM,361,RC,11104,HCPCS,outpatient,,,393,294.75,,314.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,562.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,158.14,562.17,
PSYCHOTHERAPY 60 MIN WITH PATIENT,6690837,CDM,914,RC,90837,HCPCS,outpatient,,,393,294.75,,314.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,158.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,314.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.65,314.4,
ER PLACE NEEDLE/INTRAOSSEOUS INFUSION,1400156,CDM,450,RC,36680,HCPCS,outpatient,,,394,295.5,,315.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,177.39,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,177.39,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,177.39,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,216.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,158.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,315.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,295.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,315.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,158.55,558.02,
ENDOMETRIAL BIOPSY,400033,CDM,361,RC,58100,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,239.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,153.63,320,
SFMC FHIAA CPT 83497 CHARGE ONLY,2801375,CDM,301,RC,83497,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.45,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,16.77,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,20.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.45,320,
BB MMA TEST,3000034,CDM,300,RC,86972,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,135.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,2.77,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,232.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,145.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.88,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.77,320,
INJ URETER THROUGH OSTOMY OR CATHETHER,4000015,CDM,360,RC,50684,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,114.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,114.74,320,
PR MRI LUMB/SPINE W/WO/CONTRAST,4210028,CDM,972,RC,7215826,HCPCS,outpatient,,,400,300,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,240,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,240,240,
PR MRI PELVIS W/WO CONTRAST,4210038,CDM,972,RC,7219726,HCPCS,outpatient,,,400,300,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,240,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,240,240,
PR MRI THOR/SPINE W/WO/CONTRAST,4210043,CDM,972,RC,7215726,HCPCS,outpatient,,,400,300,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,240,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,240,240,
PR MRI UPPER EXT NOT JT W/WO/CONTRAST RT,4210046,CDM,972,RC,73220RT26,HCPCS,outpatient,,,400,300,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,240,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,240,240,
PR MRI UPPER EXT NOT JT W/WO/CONTRAST LT,4210067,CDM,972,RC,73220LT26,HCPCS,outpatient,,,400,300,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,240,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,240,240,
NM PH I131 SODIUM IODIDE CAP10 mci dose,4400065,CDM,343,RC,A9517,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,23.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.59,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.73,320,
INC & DRAIN OF COMP ABSCESS,6000102,CDM,521,RC,10061,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,727.27,
REPAIR NECK HAND FEET 7.6CM TO 12.5CM,6000142,CDM,521,RC,12034,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,718.61,
"INC & DRAIN OF DEEP ABSCESS, UPPER ARM",6000154,CDM,521,RC,23930,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,3817.9,
INC & DRAIN OF COMP ABSCESS,6100044,CDM,521,RC,10061,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,727.27,
REPAIR NECK HAND FEET 7.6CM TO 12.5CM,6100072,CDM,521,RC,12034,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,718.61,
"INC & DRAIN OF DEEP ABSCESS, UPPER ARM",6100082,CDM,521,RC,23930,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,3817.9,
PREVNAR (PCV 13) VACCINE,6100450,CDM,636,RC,90670,HCPCS,both,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,400,
COLONOSCOPY- DIAGNOSTIC COLLCTN BY BRUSH,6100524,CDM,521,RC,45378,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,1622.75,
DEBRIDEMENT;SKINSUBCUTANEOUS TISSUE,6200333,CDM,510,RC,11042,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,990.21,
EXCISION OF TUMOR FOREARM,6200385,CDM,360,RC,25075,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,2843.72,
NEEDLE BIOPSY LYMPH NODE,6200578,CDM,360,RC,38505,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,2216.25,
INC & DRAIN OF COMP ABSCESS,6300086,CDM,521,RC,10061,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,727.27,
INC & DRAIN OF DEEP ABSCESS UPPER ARM,6300087,CDM,972,RC,23930,HCPCS,outpatient,,,400,300,,,,,,other,Not separately reimbursable for physician setting,207.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,240,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,210.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,210.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,207.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,207.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,210.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,210.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,207.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,337.17,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,210.73,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,295.02,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,207.55,337.17,
REPAIR NECK HAND FEET 7.6CM TO 12.5CM,6300119,CDM,521,RC,12034,HCPCS,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,718.61,
US VENOUS DOPPLER-UNILAT - RIGHT,4100035,CDM,921,RC,93971TC,HCPCS,outpatient,,,402,301.5,,321.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,161.76,321.6,
US VENOUS DOPPLER-UNILAT - LEFT,4100043,CDM,921,RC,93971TC,HCPCS,outpatient,,,402,301.5,,321.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,161.76,321.6,
SIMPLE REPAIR OF SUPER WOUND 12.6 TO 20.,6200037,CDM,510,RC,12006,HCPCS,outpatient,,,403,302.25,,322.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,221.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,322.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,302.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,162.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,322.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,162.17,551.37,
Flow cytometry interpretation 16 or mo,2801090,CDM,311,RC,88189,HCPCS,outpatient,,,405,303.75,,324,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,331.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.78,331.86,
VISTASEQ 1,2801101,CDM,301,RC,81294,HCPCS,outpatient,,,405,303.75,,324,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,202.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.2,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,222.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,263.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,263.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,263.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,263.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,263.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,263.12,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,202.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,202.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,323.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,202.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,303.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.2,324,
DO NOT USE,4110060,CDM,972,RC,10160,HCPCS,outpatient,,,405,303.75,,,,,,other,Not separately reimbursable for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,243,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,74.76,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,147.65,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,92.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,129.19,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,74.76,243,
PR CT ABD AND PELVIS WITH/WO CONTRAST,4310004,CDM,972,RC,7417826,HCPCS,outpatient,,,405,303.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,243,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,243,243,
CATHETER CORONARY DILATATION 2.75X12,5890156,CDM,278,RC,C1725,HCPCS,both,,,405,303.75,,324,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,202.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,162.97,405,
XR UPPER GI SERIES,4000196,CDM,320,RC,74240TC,HCPCS,outpatient,,,406,304.5,,324.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,163.37,324.8,
VISTASEQ 7,2801107,CDM,301,RC,81319,HCPCS,outpatient,,,407,305.25,,325.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,223.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,264.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,264.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,264.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,264.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,264.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,264.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,325.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,163.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,163.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,325.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,203.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,325.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.75,325.6,
EXC MALIGNANT LESION FACE< 0.5,6200595,CDM,510,RC,11640,HCPCS,outpatient,,,408,306,,326.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,306,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,164.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,164.18,1316.03,
PENILE BIOPSY,6200360,CDM,510,RC,54100,HCPCS,outpatient,,,409,306.75,,327.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,327.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,306.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,164.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,327.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,164.58,2843.72,
DRILL SPEED (703891),890072,CDM,278,RC,C1713,HCPCS,both,,,409.2,306.9,,327.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.06,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,286.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,164.66,869.4,
MEASLES MUMPS RUBELLA VARICELLA- MMRV,6000225,CDM,636,RC,90710,HCPCS,both,,,410,307.5,,328,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160,410,
MEASLES MUMPS RUBELLA VARICELLA,6100278,CDM,636,RC,90710,HCPCS,both,,,410,307.5,,328,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,225.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,307.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160,410,
"FRAGILE X SYNDROME, PCR SOUTHERN",2801441,CDM,311,RC,81243,HCPCS,outpatient,,,412,309,,329.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,121.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,28.52,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,226.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,74.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,165.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,165.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.26,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,85.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.52,329.6,
BICILLIN LA 1.2,3200084,CDM,636,RC,J0561,HCPCS,both,,,413.2,309.9,,330.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,330.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.24,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,330.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.16,413.2,
MOB/SPL/FLEX/COL,6200211,CDM,360,RC,44139,HCPCS,outpatient,,,414,310.5,,331.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,207,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,414,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,414,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,414,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,414,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,414,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,414,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,414,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,166.59,414,
PLEURAL DRAINAGE PERC INDW CATH W/O IMAG,6200531,CDM,360,RC,32556,HCPCS,outpatient,,,414,310.5,,331.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,166.59,2573.96,
BIOPSY OF CERVIX SINGLE/MULTIPLE OR EXCI,6900249,CDM,982,RC,57500,HCPCS,outpatient,,,414,310.5,,,,,,other,Not separately reimbursable for physician setting,82.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,248.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,82.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,72.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,72.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.42,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,116.74,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,72.96,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.14,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,72.96,248.4,
EXCISION NASAL POLYP SIMPLE,6200579,CDM,360,RC,30110,HCPCS,outpatient,,,416,312,,332.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,228.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,312,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,167.4,3047.65,
EXCISION BENIGN CYST 0.6 TO 1.0 CM,6200138,CDM,360,RC,11441,HCPCS,outpatient,,,419,314.25,,335.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,230.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,168.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,314.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,335.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,168.61,959.13,
COLONOSCOPY- CA SCREEN (NOT HIGH RISK),6100529,CDM,983,RC,G0121,HCPCS,outpatient,,,420,315,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,178.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,252,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,178.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,178.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,178.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,178.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,178.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,286.06,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,178.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,250.31,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,178.79,286.06,
PLACE CATHETER IN VEIN,6200230,CDM,360,RC,36010,HCPCS,outpatient,,,420,315,,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,169.01,1101.24,
NEW LEVEL 5 OV,6900076,CDM,982,RC,99205,HCPCS,outpatient,,,421,315.75,,,,,,other,Not separately reimbursable for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,176.33,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,252.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,176.33,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,176.33,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,176.33,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,176.33,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,176.33,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,282.13,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,176.33,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,246.86,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,122.19,282.13,
OFFICE OR OTHER O/P CONSULT-LEVEL 4,6200030,CDM,510,RC,99204,HCPCS,outpatient,,,422,316.5,,337.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57,337.6,
HARVEST CULTURED SKIN GRAFT,6200178,CDM,360,RC,15040,HCPCS,outpatient,,,422,316.5,,337.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,294.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,294.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,294.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,316.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,169.81,2550.71,
IV PUSH-INITIAL PUSH,1600005,CDM,260,RC,96374,HCPCS,outpatient,,,423,317.25,,338.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,122.66,338.4,
BIOPSY OF VAGINAL MUCOSA; SIMPLE,6100732,CDM,521,RC,57100,HCPCS,outpatient,,,423,317.25,,338.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,788.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,788.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,788.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,170.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1039.68,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,649.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,974.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,170.22,1039.68,
I&D PARONYCHIA SIMPLE FINGER ABSCESS,1400065,CDM,450,RC,26010,HCPCS,outpatient,,,424,318,,339.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,233.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,339.2,
ER-INTRAVENOUS INF HYDRATION (31-60 MIN),1400235,CDM,450,RC,96360,HCPCS,outpatient,,,424,318,,339.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,233.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.17,339.2,
HYDRATION INITIAL (31-60 MINS),1400239,CDM,260,RC,96360,HCPCS,outpatient,,,424,318,,339.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,233.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,318,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,190.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.17,339.2,
TISSUE EXAM BY PATHOLOGY,2800946,CDM,301,RC,88307,HCPCS,outpatient,,,425,318.75,,340,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,251.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,251.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,251.15,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,233.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,189.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,189.46,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,189.46,479.01,
XR COLON/SOLID COLUMN,4000187,CDM,320,RC,74270TC,HCPCS,outpatient,,,425,318.75,,340,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,171.02,340,
VISTASEQ 3,2801103,CDM,301,RC,81297,HCPCS,outpatient,,,426,319.5,,340.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.65,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,234.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,277.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,277.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,277.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,277.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,277.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,277.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.3,100,,,fee schedule,100% UHC fee schedule for outpatient setting,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,341.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,213.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,319.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,106.65,341.28,
NM PH I123 SODIUM IODIDE per 200 Uci cap,4400026,CDM,343,RC,A9516,HCPCS,outpatient,,,426,319.5,,340.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,171.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,171.42,340.8,
PANCREASTATIN,2801023,CDM,306,RC,83519,HCPCS,outpatient,,,427,320.25,,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,234.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.33,341.6,
NEUROKININ A,2801024,CDM,306,RC,83519,HCPCS,outpatient,,,427,320.25,,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,16.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9.19,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,234.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,23.92,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,6.33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,29.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.6,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.33,341.6,
XR FLUORO-NEEDLE PLACEMENT,4000192,CDM,320,RC,77002TC,HCPCS,outpatient,,,427,320.25,,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,213.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.85,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,171.82,341.6,
SIMPLEX HV WITH GENTAMYCIN,890267,CDM,278,RC,C1713,HCPCS,both,,,427.36,320.52,,341.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,171.97,869.4,
VIRAL PANEL PCR,2801418,CDM,302,RC,0240U,HCPCS,outpatient,,,428,321,,342.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.31,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,235.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,228.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.31,342.4,
VIRAL PANEL W/ RSV,2801419,CDM,302,RC,0241U,HCPCS,outpatient,,,428,321,,342.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.31,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,235.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,228.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.31,342.4,
VIRAL PANEL W/RSV SEND-OUT,2801437,CDM,306,RC,87637,HCPCS,outpatient,,,428,321,,342.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.31,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,235.4,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,185.42,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,142.63,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,228.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,142.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,71.31,342.4,
SPLINTING:SHORT ARM,1400194,CDM,450,RC,29125,HCPCS,outpatient,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,344,
ANGIOSEALS VIP 6FR,5890031,CDM,278,RC,C1760,HCPCS,both,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.03,430,
CATHETER CORONARY TREK DILATATION 3.50MM,5890059,CDM,278,RC,C1725,HCPCS,both,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.03,430,
CATHETER CORONARY DILATATION,5890132,CDM,278,RC,C1725,HCPCS,both,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.03,430,
ANGIOSEALS 6 FR,90000055,CDM,278,RC,C1760,HCPCS,both,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.03,430,
CATHETER TREK CORONARY DILATATION,90006734,CDM,278,RC,C1725,HCPCS,both,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.03,430,
VAXNEUVANCE 0.5 ML,3207171,CDM,636,RC,90671,HCPCS,both,,,430.62,322.97,,344.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.28,430.62,
VAXNEUVANCE 0.5 ML,6000300,CDM,636,RC,90671,HCPCS,both,,,430.62,322.97,,344.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.28,430.62,
VAXNEUVANCE 0.5 ML,6105000,CDM,636,RC,90671,HCPCS,both,,,430.62,322.97,,344.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.28,430.62,
EXCISION OF TONGUE LESION W/O CLOSURE,6200157,CDM,360,RC,41110,HCPCS,outpatient,,,431,323.25,,344.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4204.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.43,4204.78,
PNEUMOCOCCAL (PREVNAR 13),6900034,CDM,982,RC,90670,HCPCS,outpatient,,,431,323.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,257.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,258.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,257.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,257.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,257.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,257.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,257.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,412.78,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,257.99,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,361.19,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,257.99,412.78,
BLOOD ADM,2400009,CDM,391,RC,36430,HCPCS,outpatient,,,432,324,,345.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,602.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.84,690.5,
BB ALBUMIN ADINISTRATION,3000002,CDM,391,RC,96367,HCPCS,outpatient,,,432,324,,345.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,122.66,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,58.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,62.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,93.47,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.19,345.6,
BB BLOOD ADMINISTRATION,3000004,CDM,391,RC,36430,HCPCS,outpatient,,,432,324,,345.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,237.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,602.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.84,690.5,
CT LOW DOSE CHEST W/O CONTRAST SCREENING,4300073,CDM,352,RC,G0297,HCPCS,outpatient,,,432,324,,345.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,216,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.84,650,
CRYSTOURETHROSCOPY SEPARATE PROCEDURE,6100695,CDM,969,RC,52000,HCPCS,outpatient,,,432,324,,,,,,other,Not separately reimbursable for physician setting,142.47,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,259.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,78.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,78.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,142.47,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,142.47,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,78.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,78.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,142.47,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,125.14,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,78.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,109.49,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,78.21,259.2,
EXC BENIGN LESION 1.1 TO 2.0CM,6200110,CDM,360,RC,11422,HCPCS,outpatient,,,433,324.75,,346.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,238.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,174.24,2216.25,
SFMC BK VIRUS DNA QUANTITATIVE,2800781,CDM,301,RC,87799,HCPCS,outpatient,,,434,325.5,,347.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,238.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.55,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.55,347.2,
BCR-ABL1 CHARGE ONLY,2801405,CDM,310,RC,81207,HCPCS,outpatient,,,434,325.5,,347.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,381.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,381.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,381.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,72.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,238.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,188.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,188.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,188.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,188.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,188.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,188.29,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,144.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,144.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,144.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,144.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,231.74,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,144.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,217.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.42,381.4,
XR FLUORO FOR SPINE INJECTION,4000191,CDM,320,RC,77003TC,HCPCS,outpatient,,,434,325.5,,347.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.7,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,174.64,347.2,
REMOVAL FOREIGN BODY;FOOT SUBSUTANEOUS,6200362,CDM,510,RC,28190,HCPCS,outpatient,,,434,325.5,,347.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,238.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,174.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,174.64,959.13,
INSERTION OF NG TUBE,1400231,CDM,761,RC,43753,HCPCS,outpatient,,,436,327,,348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,147.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,147.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,147.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,239.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,327,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,147.29,413.91,
PR BX SALIVARY GLAND,4210082,CDM,972,RC,42400,HCPCS,outpatient,,,436,327,,,,,,other,Not separately reimbursable for physician setting,64.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,50.6,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,261.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,50.6,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,50.6,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,50.6,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,64.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,50.6,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,50.6,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,80.96,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,50.6,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,70.84,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,50.6,261.6,
IRRIGATION BLADDER,1400237,CDM,761,RC,51700,HCPCS,outpatient,,,438,328.5,,350.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,350.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,350.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,176.25,350.4,
ER BLADDER IRRIGATION SIMPLE,1400017,CDM,450,RC,51700,HCPCS,outpatient,,,439,329.25,,351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,219.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,176.65,351.2,
INITIAL OBSERVATION CARE-LEVEL2,6200019,CDM,510,RC,99219,HCPCS,outpatient,,,439,329.25,,351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,351.2,
INCISION & DRAINAGE FINGER SIMPLE,6200187,CDM,360,RC,26010,HCPCS,outpatient,,,439,329.25,,351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,286.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,329.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,351.2,
ANA COMPREHENSIVE PROFILE,2801081,CDM,302,RC,86225,HCPCS,outpatient,,,440,330,,352,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,48.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.87,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,242,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,17.86,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,330,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.87,352,
CMV DNA QUANT,2800173,CDM,300,RC,87497,HCPCS,outpatient,,,442,331.5,,353.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,243.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,331.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,331.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.42,353.6,
MM MAMMOGRAM DIAGNOSTIC BILATERAL*,4000208,CDM,401,RC,77066,HCPCS,outpatient,,,443,332.25,,354.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,150.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,150.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,99.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,243.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,99.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.02,100,,,fee schedule,100% UHC fee schedule for outpatient setting,178.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158.77,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,99.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,148.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.23,354.4,
BICILLIN LA 600000,3200086,CDM,636,RC,J0561,HCPCS,both,,,443.5,332.63,,354.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,243.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,354.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.24,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,354.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.16,443.5,
INITIAL HOSPITAL CARE-ADMIT-LEVEL 1,6200012,CDM,963,RC,99222,HCPCS,outpatient,,,445,333.75,,,,,,other,Not separately reimbursable for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,267,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,85.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,203.54,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,127.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,178.09,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,85.35,267,
INITIAL INPATIENT CONSULT-LEVEL 2,6200015,CDM,510,RC,99252,HCPCS,outpatient,,,445,333.75,,356,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.07,356,
EXCISION OF ANAL LESION,6200149,CDM,360,RC,46922,HCPCS,outpatient,,,445,333.75,,356,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3837.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3837.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3837.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,244.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,333.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.07,3837.02,
FBR: PHARYNX,1400083,CDM,450,RC,42809,HCPCS,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.34,558.02,
ER FB-CONJUN  EMBEDDED,1400084,CDM,450,RC,65210,HCPCS,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.47,558.02,
FBR:CORNEA,1400086,CDM,450,RC,65220,HCPCS,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.47,558.02,
ER VEIN CUTDOWN 1 YR OR OLDER,1400218,CDM,450,RC,36425,HCPCS,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.8,558.02,
REHAB VISIT LEVEL 2,6100253,CDM,511,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
HTLV-I/II DNA BY PCR,2800368,CDM,301,RC,87798,HCPCS,outpatient,,,446,334.5,,356.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,123.94,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,17.54,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,245.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,45.62,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.54,356.8,
WOUND CARE NON-SELECTIVE,1400257,CDM,761,RC,97602,HCPCS,outpatient,,,448,336,,358.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,358.4,
XR ASPIRATION/INJECTION LARGE JOINT BURS,4001138,CDM,330,RC,20610,HCPCS,outpatient,,,448,336,,358.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,336,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,180.28,429.76,
STENT POLARIS ULTRA URETERAL M0061921350,490002,CDM,278,RC,C2617,HCPCS,both,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,450,
STENT POLARIS ULTRA URETERAL M0061921320,490003,CDM,278,RC,C2617,HCPCS,both,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,450,
IMMUNE ADMIN ORAL/NASAL ADDITIONAL,6100259,CDM,771,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
QUAD SCREEN,2801089,CDM,301,RC,81511,HCPCS,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,327.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,327.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,327.42,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,76.75,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,199.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,199.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,199.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,199.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,199.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,199.55,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,245.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,153.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,230.25,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.75,360,
INJ SINUS TRACT DIAGNOSTIC,4000014,CDM,360,RC,20501,HCPCS,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,92.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,92.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,92.35,360,
PR MRI LOWER EXT JOINT W&W/0 CONTRAST RT,4210011,CDM,972,RC,7372326RT,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,270,270,
PR MRI CHEST W&W/O CONTRAST,4210020,CDM,972,RC,7155226,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,270,270,
PR MRI LOWER EXT JOINT W&W/0 CONTRAST LT,4210050,CDM,972,RC,7372326LT,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,270,270,
PR MRA ABD W & W/O CONTRAST,4210074,CDM,972,RC,C8902,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,270,270,
PR MRA PELVIS W&W/O CONTRAST,4210080,CDM,972,RC,C8920,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,270,270,
PR CTA ABD & PELVIS W/WO CONTRAST,4310046,CDM,972,RC,7417426,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,270,270,
JADE PTA BALLOON 2.5MM X 150MM,5890104,CDM,278,RC,C1725,HCPCS,both,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,450,
EXAM OF VAGINA W/SCOPE,6100123,CDM,521,RC,57420,HCPCS,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,451.36,
EXAM OF CERVIX W/SCOPE,6100125,CDM,521,RC,57452,HCPCS,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,153.63,451.36,
ENDOERV CURETTAGE W/SCOPE,6100128,CDM,521,RC,57456,HCPCS,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,451.36,
EGD W/BIOPSY,6100504,CDM,982,RC,43239,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,212.64,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,133.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,133.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,133.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,133.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,212.64,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,212.64,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,133.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,133.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,212.64,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,213.1,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,133.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,186.47,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,133.19,270,
COLONOSCOPY (MEDICARE HI RISK),6100537,CDM,521,RC,G0105,HCPCS,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,1228.22,
EXAM OF VAGINA WITH SCOPE,6200413,CDM,360,RC,57420,HCPCS,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,451.36,
SWING BED DISCHARGE-MORE THAN 30 MINS,7000033,CDM,982,RC,99316,HCPCS,outpatient,,,450,337.5,,,,,,other,Not separately reimbursable for physician setting,52.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,270,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,127.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,127.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,52.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,52.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,127.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,127.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,52.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,203.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,127.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,178.23,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,52.46,270,
SLITTING OF PREPUCE (NOT NEWBORN),6200291,CDM,360,RC,54001,HCPCS,outpatient,,,453,339.75,,362.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3367.98,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3367.98,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3367.98,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,249.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,182.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,182.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,362.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,182.29,3367.98,
PR CTA ABDOMINAL AORTA,4310047,CDM,972,RC,7563526,HCPCS,outpatient,,,458,343.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,274.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,274.8,274.8,
THERAPEUTIC SERVC USE OF SPEECH DEVICE,5100636,CDM,440,RC,92609GN,HCPCS,outpatient,,,459,344.25,,367.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,229.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,229.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,229.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,184.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,367.2,
ADD-ON EACH UP TO 10 LESIONS OR PART,6900007,CDM,982,RC,11201,HCPCS,outpatient,,,459,344.25,,,,,,other,Not separately reimbursable for physician setting,11.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,275.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,16.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,16.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,16.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,11.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,11.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,16.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,16.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,11.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,25.79,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,16.12,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,22.57,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,11.6,275.4,
CRYOSURGERY 1.1 TO 2.0,6900014,CDM,982,RC,17262,HCPCS,outpatient,,,459,344.25,,,,,,other,Not separately reimbursable for physician setting,101.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,275.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,105.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,105.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,101.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,101.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,105.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,105.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,101.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,169.36,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,105.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,148.19,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,101.6,275.4,
HEPATITIS C GENOTYPE NON REFLEX,2800323,CDM,306,RC,87902,HCPCS,outpatient,,,460,345,,368,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,253,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,411.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.72,909.01,
HYALGAN 20MG/2ML PFS 2ML,3204268,CDM,636,RC,J7321,HCPCS,both,,,460,345,,368,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,230,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.1,460,
VOYAGER -ABBOTT,5800196,CDM,270,RC,C1725,HCPCS,outpatient,,,460,345,,368,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,230,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.1,368,
US GUIDE CATHETER FLUID DRAIN,6200585,CDM,360,RC,10030,HCPCS,outpatient,,,460,345,,368,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,508.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,508.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,508.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,253,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,345,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.1,959.13,
MEASLES MUMPS REBELLA VARICELLA PROQUAD,6900047,CDM,982,RC,90710,HCPCS,outpatient,,,460,345,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,276,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,276,276,
PR CT LOW DOSE CT SCREENING,4310073,CDM,972,RC,G029726,HCPCS,outpatient,,,462,346.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,277.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,277.2,277.2,
PLATE 3 HOLE STRAIGHT,890174,CDM,278,RC,C1713,HCPCS,both,,,463.54,347.66,,370.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,186.53,869.4,
PLATE 2 HOLE STRAIGHT,890175,CDM,278,RC,C1713,HCPCS,both,,,463.54,347.66,,370.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,186.53,869.4,
SCREW 6.5 CANN 90MM,890019,CDM,278,RC,C1713,HCPCS,both,,,465,348.75,,372,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.12,869.4,
FLUORO SPINE INJECTION/SURGICAL,4000003,CDM,320,RC,77003TC,HCPCS,outpatient,,,465,348.75,,372,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,232.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.12,372,
DRAIN THYROID/TONGUE CYST,6200521,CDM,360,RC,60000,HCPCS,outpatient,,,465,348.75,,372,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,348.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.12,2051.58,
EXCISION BENIGN CYST 1.1 TO 2.0CM,6200139,CDM,360,RC,11442,HCPCS,outpatient,,,466,349.5,,372.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,256.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,187.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.52,1316.03,
SCREW 6.5MM CANN 75MM,890076,CDM,278,RC,C1713,HCPCS,both,,,466.6,349.95,,373.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,187.76,869.4,
INTRAOPER ID MAPPING OF SENTINELNODE,6200197,CDM,360,RC,38900,HCPCS,outpatient,,,469,351.75,,375.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,234.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,234.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,188.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,188.73,375.2,
HYSTEROSCOPY,6100724,CDM,981,RC,58555,HCPCS,outpatient,,,470,352.5,,,,,,other,Not separately reimbursable for physician setting,155.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,149.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,282,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,149.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,155.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,155.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,149.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,149.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,155.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,238.42,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,149.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,208.61,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,149.01,282,
UNLISTED FLUOROSCOPIC PROCEDURE,6200309,CDM,360,RC,76496,HCPCS,outpatient,,,470.01,352.51,,376.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,102.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,102.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,258.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,74.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,352.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.44,100,,,fee schedule,100% UHC fee schedule for outpatient setting,189.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,376.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.93,376.01,
STRESS TEST NUCLEAR WALKING,5500003,CDM,482,RC,93017,HCPCS,outpatient,,,471,353.25,,376.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,379.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,379.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,259.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,189.53,413.91,
STRESS TEST INTERP&REPORT,5500005,CDM,731,RC,93016,HCPCS,outpatient,,,471,353.25,,376.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,119.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119.93,376.8,
SCREW 3.5MM LOCKING 20MM,890147,CDM,278,RC,C1713,HCPCS,both,,,472,354,,377.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,189.93,869.4,
EEG A/D WITH PS/HV,5600006,CDM,740,RC,95816,HCPCS,outpatient,,,472,354,,377.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,259.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,354,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,189.93,413.89,
PATIENT EDUCATION,5200011,CDM,410,RC,94664,HCPCS,outpatient,,,473,354.75,,378.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,52.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,260.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.33,378.4,
BIPAP/CPAP,5200029,CDM,410,RC,94660,HCPCS,outpatient,,,473,354.75,,378.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,260.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,165.16,378.4,
PENT TREATMENT,5200063,CDM,410,RC,94642,HCPCS,outpatient,,,473,354.75,,378.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,156.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,260.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,165.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,354.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,176.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.13,378.4,
FLUORO/BX/FNA SURGICAL,4000004,CDM,320,RC,77002TC,HCPCS,outpatient,,,474,355.5,,379.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,237,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.7,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,190.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,190.74,379.2,
EXCISION BENIGN LESION:2.1 TO 3.0 CM,6200340,CDM,510,RC,11403,HCPCS,outpatient,,,475,356.25,,380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.14,1316.03,
REPLACE G-J TUBE PERCUTANEOUS,6200434,CDM,360,RC,49452,HCPCS,outpatient,,,475,356.25,,380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,657.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,657.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,657.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.14,1220.05,
NEW PT LEVEL 1 OV,6100308,CDM,521,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NEW PT LEVEL 2 OV,6100309,CDM,521,RC,,,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
NEW PT LEVEL 3 OV,6100310,CDM,521,RC,,,outpatient,,,140,105,,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,56.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.34,112,
NEW PT LEVEL 4 OV,6100311,CDM,521,RC,,,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
NEW PT LEVEL 5 OV,6100312,CDM,521,RC,,,outpatient,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.54,180,
FB REMOVAL MUSCLE/TENDON SHEALTH SIMPLE,6200596,CDM,510,RC,20520,HCPCS,outpatient,,,475,356.25,,380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,356.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,191.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.14,2216.25,
VISTASEQ 5,2801105,CDM,301,RC,81300,HCPCS,outpatient,,,476,357,,380.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,261.8,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,309.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,309.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,309.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,309.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,309.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,309.4,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,238,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,238,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,238,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,357,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238,100,,,fee schedule,100% UHC fee schedule for outpatient setting,191.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,380.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,238,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,357,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,119,380.8,
EST LEVEL 3 OV W/MODIFIER -25,6100315,CDM,521,RC,,,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
EST LEVEL 4 OV,6100316,CDM,521,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
EST LEVEL 5 OV,6100317,CDM,521,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
LINGUAL FRENULECTOMY,6200206,CDM,360,RC,41115,HCPCS,outpatient,,,477,357.75,,381.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,262.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,191.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,381.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,357.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,381.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.94,2051.58,
PR THYROID BIOPSY IN RADIOLOGY,4010199,CDM,972,RC,60100,HCPCS,outpatient,,,478,358.5,,,,,,other,Not separately reimbursable for physician setting,73.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,286.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,75.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,75.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,75.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,73.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,73.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,75.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,75.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.78,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,121.39,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,75.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.22,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,73.78,286.8,
PR FINE NEEDLE ASP IN RAD.*,4010214,CDM,972,RC,10005,HCPCS,outpatient,,,479,359.25,,,,,,other,Not separately reimbursable for physician setting,91.79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,287.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,72.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,72.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,91.79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,72.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,72.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,91.79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,115.82,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,72.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,101.35,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,72.39,287.4,
OXYGEN THERAPY,5200109,CDM,460,RC,94680,HCPCS,outpatient,,,480,360,,384,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,99.81,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,264,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.5,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,99.81,384,
EXCISION MAL LESION 0.6 TO 1.0CM,6200145,CDM,360,RC,11601,HCPCS,outpatient,,,481,360.75,,384.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,264.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,193.55,959.13,
FINGER IPJ DISLOCATION:WO ANESTHESIA,1400031,CDM,450,RC,26770,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
ER CLO TX METACARPAL FX WO MANIPULATION,1400033,CDM,450,RC,26600,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
ER CLO TX METACARPOPHALANGEAL DISLOC,1400034,CDM,450,RC,26700,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
ER CLO TX RADIAL HEAD/NECK FX WO MANIP,1400038,CDM,450,RC,24650,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
ER CLO TX RIB FX UNCOMPLICATED-EACH,1400041,CDM,450,RC,21800,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,194.36,386.4,
ER CLO TX ULNAR SHAFT FX WO MANIPULATION,1400045,CDM,450,RC,25530,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
TOE MP DISLOCATION,1400272,CDM,450,RC,28630,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
CLOSED TX FINGER OR THUMB,1400277,CDM,450,RC,26720,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
CLOSED TX FINGER W MANIPULATION,1400278,CDM,450,RC,26725,HCPCS,outpatient,,,483,362.25,,386.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,386.4,
XR UGI WITH SBFT,4000195,CDM,320,RC,74245TC,HCPCS,outpatient,,,485,363.75,,388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,242.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,195.16,388,
BRONCHOSCOPY DIAGNOSTIC,6200326,CDM,510,RC,31622,HCPCS,outpatient,,,485,363.75,,388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,266.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,363.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,195.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,195.16,2362.57,
ZOSTAVAX .65ML,6900056,CDM,982,RC,90736,HCPCS,outpatient,,,485,363.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,291,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,291,291,
EXC MALIGNANT LESION 0.6CM TO 1.0CM,6200125,CDM,360,RC,11621,HCPCS,outpatient,,,486,364.5,,388.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,267.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,364.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,388.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,195.57,959.13,
BRONCHOSCOPY DIAGNOSTIC BRUSH,6200072,CDM,360,RC,31623,HCPCS,outpatient,,,488,366,,390.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,268.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,196.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,196.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,390.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,366,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,390.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,196.37,2362.57,
ER LEVEL 3,1400145,CDM,450,RC,99283,HCPCS,outpatient,,,491,368.25,,392.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,331.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,226.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,197.58,491,
ER LEVEL 3 - MODIFIER,1400146,CDM,450,RC,9928325,HCPCS,outpatient,,,491,368.25,,392.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,245.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,197.58,392.8,
BCR-ABL1 FOR CML AND ALL QUANTITATIVE,2801404,CDM,310,RC,81206,HCPCS,outpatient,,,492,369,,393.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,431.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,431.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,431.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,81.98,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,270.6,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,213.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,213.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,213.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,213.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,213.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,213.15,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,163.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,163.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% UHC fee schedule for outpatient setting,163.96,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,262.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,81.98,431.76,
PREVNAR 20,3207765,CDM,636,RC,90677,HCPCS,both,,,492.5,369.38,,394,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,198.18,492.5,
PREVNAR 20,6100888,CDM,636,RC,90677,HCPCS,both,,,492.5,369.38,,394,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,198.18,492.5,
REPAIR INT LESS THAN 2.5CM,6200277,CDM,360,RC,12031,HCPCS,outpatient,,,493,369.75,,394.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,271.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,198.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,369.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,198.38,718.61,
MOTION FLUORO EVAL SWALLOW FUCTN VIDEO,5100532,CDM,440,RC,92611GN,HCPCS,outpatient,,,494,370.5,,395.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,247,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,395.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,395.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,395.2,
XR COLON/AIR CONTRAST,4000044,CDM,320,RC,74280TC,HCPCS,outpatient,,,497,372.75,,397.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,248.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,199.99,397.6,
XR COLON/AIR CONTRAST,4000186,CDM,320,RC,74280TC,HCPCS,outpatient,,,497,372.75,,397.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,248.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,199.99,397.6,
PLATE 5 HOLE STRAIGHT,890123,CDM,278,RC,C1713,HCPCS,both,,,498.82,374.12,,399.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,200.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,274.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,200.73,869.4,
JAK2 MUTATION ANALYSIS QUALITATIVE,2800949,CDM,305,RC,85045,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,14.13,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.99,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,5.19,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,3.99,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,6.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.98,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.99,400,
FINE NEEDLE ASPIRATION IN RAD.,4000200,CDM,360,RC,10022,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
PR XR VENOGRAM EXTREMITY BILATERAL,4010132,CDM,972,RC,7582226,HCPCS,outpatient,,,500,375,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,300,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,300,300,
EXC TR-EXT B9+MARG>4.0,6000124,CDM,521,RC,11406,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,2843.72,
"INSERT, NON BIODEGRADABLE DRUG DELIVERY",6000134,CDM,521,RC,11981,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,400,
"INCISION & DRAINAGE,FOREARM,ABSCESS",6000155,CDM,521,RC,25028,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,4399.33,
EXC TR-EXT B9+MARG>4.0,6100062,CDM,521,RC,11406,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,2843.72,
"INCISION & DRAINAGE,FOREARM,ABSCESS",6100083,CDM,521,RC,25028,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,4399.33,
EXC ABD TUMOR 5CM OR LESS,6100100,CDM,521,RC,49203,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,500,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,6043.61,
HYSTEROSCOPY BIOPSY,6100153,CDM,521,RC,58558,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,4178.79,
"INSERT, NON BIODEGRADABLE DRUG DELIVERY",6100455,CDM,521,RC,11981,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,400,
EGD CAUTERY TUMOR POLYP,6100545,CDM,982,RC,43250,HCPCS,outpatient,,,500,375,,,,,,other,Not separately reimbursable for physician setting,124.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,164.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,300,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,164.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,164.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,164.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,124.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,124.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,164.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,164.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,124.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,263.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,164.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,230.73,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,124.22,300,
CIRCUMCISION WITH REGONAL DORSAL,6200077,CDM,360,RC,54150,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,3748.83,
"EXCISION THROMBOSED HEMORRHOID, EXTERNAL",6200158,CDM,360,RC,46320,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,1600.47,
UPPER GI ENDOSCOPY EGD,6200369,CDM,510,RC,43235,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,1529.37,
REM FB UPPER ARM ELBOW SUBCUTANEOUS,6200419,CDM,360,RC,24200,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,2216.25,
LAPAROSCOPE PROCDURE INTESTINE,6200462,CDM,360,RC,44238,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,7703.27,
THORACENTESIS WITH IMAGING GUIDANCE,6200469,CDM,360,RC,32555,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,1313.87,
HYSTEROSCOPY SURG W/ENDOMETRIAL BX &AMP,6200620,CDM,360,RC,58558,HCPCS,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,4178.79,
INCISION & DRAINAGE FOREARM ABSCESS,6300088,CDM,972,RC,25028,HCPCS,outpatient,,,500,375,,,,,,other,Not separately reimbursable for physician setting,309.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,500,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,300,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,500,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,500,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,500,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,309.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,309.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,500,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,500,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,309.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,800,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,500,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,700,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,300,800,
EXCISION OF BENIGN LESION  1 -2 CM,6900260,CDM,982,RC,11422,HCPCS,outpatient,,,500,375,,,,,,other,Not separately reimbursable for physician setting,100.21,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,129.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,300,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,129.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,129.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,129.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.21,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,100.21,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,129.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,129.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100.21,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,206.85,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,129.28,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,180.99,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,100.21,300,
CRITICAL CARE LEVEL 2,7000035,CDM,982,RC,99292,HCPCS,outpatient,,,500,375,,,,,,other,Not separately reimbursable for physician setting,79.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,300,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,105.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,105.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,105.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,79.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,79.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,105.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,105.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,79.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,168.88,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,105.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,147.77,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,79.38,300,
INSTU HYBRIDIZATION MANUAL,2800976,CDM,301,RC,88368,HCPCS,outpatient,,,501,375.75,,400.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,184.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,184.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,184.03,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,275.55,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,100.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.41,100,,,fee schedule,100% UHC fee schedule for outpatient setting,100.19,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,479.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,299.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.07,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,400.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.19,479.01,
EXCISION MALIGNANT LESION 0.6 TO 1.0CM,6200163,CDM,360,RC,11641,HCPCS,outpatient,,,505,378.75,,404,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,378.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.21,1316.03,
REPAIR INTERMEDIATE WOUNDS NECK,6200270,CDM,360,RC,12041,HCPCS,outpatient,,,506,379.5,,404.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.61,551.37,
EGD WITH INSERTION OF TUBE OR CATHETER,6200493,CDM,360,RC,43241,HCPCS,outpatient,,,506,379.5,,404.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,379.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,203.61,2573.96,
EXCISION BENIGN LESION 2.1 TP 3.0,6200381,CDM,360,RC,11423,HCPCS,outpatient,,,508,381,,406.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,381,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,406.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.42,2843.72,
HLA A29 UVEITIS,2801305,CDM,305,RC,81381,HCPCS,outpatient,,,510,382.5,,408,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,362.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,362.39,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,84.95,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,280.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,220.87,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% UHC fee schedule for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,254.85,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.95,408,
BIOPSY OF NECK/CHEST,6200067,CDM,360,RC,21550,HCPCS,outpatient,,,512,384,,409.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.03,2843.72,
PERQ DRAINAGE PLEURA INSERT CATH W/IMAGE,6200615,CDM,360,RC,32557,HCPCS,outpatient,,,514,385.5,,411.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,282.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.83,2198.94,
DEBRIDEMENT OF SKIN,6200379,CDM,360,RC,11043,HCPCS,outpatient,,,515,386.25,,412,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,283.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,207.24,1555.4,
BX BREAST PERCUT W/IMAGE,6200451,CDM,360,RC,19102,HCPCS,outpatient,,,515,386.25,,412,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,207.24,412,
BANDAGE ACE 4,6100381,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
BANDAGE ACE 6,6100382,CDM,270,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
BANDAGE ACE 2,6100383,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
BANDAGE ACE 3,6100384,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
CATHETER DECLOTTING,1400007,CDM,761,RC,36593,HCPCS,outpatient,,,520,390,,416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,156.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,156.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,156.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,491.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,460.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,156.95,491.58,
US PUNCTURE ASPIRATION ABCESS,4100066,CDM,360,RC,10160,HCPCS,outpatient,,,522,391.5,,417.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,261,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,210.05,551.37,
US PUNCTURE ASPIRATION ABCESS,4100067,CDM,360,RC,10160,HCPCS,outpatient,,,522,391.5,,417.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,261,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,391.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,210.05,551.37,
EXCISION BENIGN LESION 3.1CM TO 4.0CM,6200140,CDM,360,RC,11404,HCPCS,outpatient,,,524,393,,419.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,210.86,2843.72,
DEEP MUSCLE BIOPSY,6200407,CDM,360,RC,20205,HCPCS,outpatient,,,524,393,,419.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,210.86,3817.9,
Negative Pressure Therapy >50 sq cm,65097608,CDM,510,RC,97608,HCPCS,outpatient,,,524,393,,419.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,295.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,295.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,295.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,210.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,210.86,551.37,
EGD WITH BIOPSY,6200338,CDM,510,RC,43239,HCPCS,outpatient,,,525,393.75,,420,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,211.26,1529.37,
Biopsy and scraping of the cervix and en,6900237,CDM,982,RC,57454,HCPCS,outpatient,,,525,393.75,,,,,,other,Not separately reimbursable for physician setting,100.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,130.7,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,315,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,130.7,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,130.7,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,130.7,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,100.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,100.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,130.7,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,130.7,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,100.35,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,209.12,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,130.7,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,182.98,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,100.35,315,
PRE-OP/POST-OP,6100394,CDM,521,RC,99213,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,154.55,154.55,
Colposcopy of cervix with endocervical c,6900238,CDM,982,RC,57456,HCPCS,outpatient,,,525,393.75,,,,,,other,Not separately reimbursable for physician setting,87.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,315,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,87.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,87.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,87.46,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,159.76,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,99.85,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.79,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,87.46,315,
Incision and drainage of Bartholin gland,6900240,CDM,982,RC,56420,HCPCS,outpatient,,,525,393.75,,,,,,other,Not separately reimbursable for physician setting,79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,107.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,315,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,107.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,107.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,107.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,107.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,107.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,79,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,172.42,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,107.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,150.86,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,79,315,
BIOPSY OF VULVA OR PERINEUM ONE LESION,6900241,CDM,982,RC,56605,HCPCS,outpatient,,,525,393.75,,,,,,other,Not separately reimbursable for physician setting,53.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,58.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,315,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,58.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,58.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,58.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,53.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,53.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,58.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,58.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,53.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,94.06,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,58.79,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.31,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,53.49,315,
Colposcopy of the cervix including upper,6900242,CDM,982,RC,57460,HCPCS,outpatient,,,525,393.75,,,,,,other,Not separately reimbursable for physician setting,187.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,157.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,315,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,157.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,157.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,157.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,187.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,187.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,157.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,157.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,187.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,251.31,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,157.07,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,219.9,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,157.07,315,
NANOCROSS ELITE EV3 2.5MM,90006888,CDM,278,RC,C1725,HCPCS,both,,,525,393.75,,420,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,211.26,525,
EMPLOYEE PHYSICIAL,6100407,CDM,521,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
DOT EXAM,6100408,CDM,521,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
EXCISION MALIGN LESION 1.1 TO 2 CM,6200146,CDM,360,RC,11602,HCPCS,outpatient,,,527,395.25,,421.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,289.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,395.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,421.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,212.06,786.48,
DRAINAGE RECTAL ABSCESS,6200557,CDM,510,RC,45005,HCPCS,outpatient,,,528,396,,422.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,290.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,212.47,3024.11,
BIOPSY ARM FOREARM SOFT TISSUE SUPERFICI,6200562,CDM,360,RC,25065,HCPCS,outpatient,,,528,396,,422.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,290.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,212.47,2843.72,
NASAL/SINUS ENDOSCOPY FB REMOVAL,6200406,CDM,360,RC,31237,HCPCS,outpatient,,,531,398.25,,424.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4024.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4024.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4024.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,292.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,213.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,424.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,398.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,424.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,213.67,4024.46,
PLACE CATHETER IN AORTA,6200229,CDM,360,RC,36200,HCPCS,outpatient,,,532,399,,425.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,214.08,1101.24,
BREAST BIOPSY 1ST LESION ULTRASOUND GUID,6200530,CDM,360,RC,19083,HCPCS,outpatient,,,532,399,,425.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,292.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,399,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,214.08,2216.25,
US CAROTID DOPPLER UNI/LIMITED,4100011,CDM,921,RC,93882TC,HCPCS,outpatient,,,535,401.25,,428,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,267.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,215.28,428,
US CAROTID DOPPLER UNI/LIMITED,4100041,CDM,921,RC,93882TC,HCPCS,outpatient,,,535,401.25,,428,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,267.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,215.28,428,
NANOCROSS EV3 ELITE 3.0 X 40MM,5890086,CDM,278,RC,C1725,HCPCS,both,,,535.5,401.63,,428.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,267.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,215.49,535.5,
NANOCROSS EV3 ELITE DILATATION CATHETER,5890118,CDM,278,RC,C1725,HCPCS,both,,,535.6,401.7,,428.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,267.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,215.53,535.6,
PLACE CATHETER IN VEIEN,6200552,CDM,510,RC,36011,HCPCS,outpatient,,,536,402,,428.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,215.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,215.69,1101.24,
PLATE STRAIGHT 8 HOLES,890222,CDM,278,RC,C1713,HCPCS,both,,,540,405,,432,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,217.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,217.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,217.3,869.4,
OFFICE OR OTHER O/P CONSULT-LEVEL 5,6200031,CDM,510,RC,99205,HCPCS,outpatient,,,549,411.75,,439.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,439.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,439.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57,439.2,
IVC FILTER PLACEMENT S&I,5800096,CDM,320,RC,75940,HCPCS,outpatient,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,440,
COMPLICATED INCISION & REMOVAL FOREIGN,6000104,CDM,521,RC,10121,HCPCS,outpatient,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,4382.34,
COMPLICATED INCISION & REMOVAL FOREIGN,6100046,CDM,521,RC,10121,HCPCS,outpatient,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,4382.34,
CHEST SURGERY PROCEDURE UNLISTED,6200572,CDM,360,RC,32999,HCPCS,outpatient,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,609.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,609.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,609.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,854.99,
CATHETER PTCA DILATATION 1.50MM,90006671,CDM,278,RC,C1725,HCPCS,both,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,550,
CATHETER PTCA DILATATION MONORAIL EMERGE,90007128,CDM,278,RC,C1725,HCPCS,both,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,550,
HIV RAPID TEST,6100428,CDM,300,RC,86703,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,6.85,37.27,
DRAINAGE OF PILONDAL CYST,6200095,CDM,360,RC,10081,HCPCS,outpatient,,,551,413.25,,440.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,303.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,413.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,440.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.72,959.13,
1ST ORDER BELOW (LOWER EXT),5800001,CDM,480,RC,36245,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,1101.24,
1ST ORDER BELOW(UPPER EXT),5800002,CDM,480,RC,36215,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,1101.24,
2ND ORDER BELOW(LOWER EXT),5800003,CDM,480,RC,36246,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,1101.24,
2ND ORDER BELOW(UPPER EXT),5800004,CDM,480,RC,36216,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,1101.24,
3RD ORDER BELOW(LOWER EXT),5800005,CDM,480,RC,36247,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,1101.24,
ADD BRANCH SAME VESS(UPPER EXT),5800015,CDM,480,RC,36218,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,1101.24,
INJ SEL CORD ANGIO,5800083,CDM,480,RC,93454,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,8687.74,
PULLBACK ARTERY SAME SIDE STICK,5800154,CDM,480,RC,36140,HCPCS,outpatient,,,552,414,,441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.12,1101.24,
SCREW 6.5MM ASNIS 3 (95MM),890281,CDM,278,RC,C1713,HCPCS,both,,,553.34,415.01,,442.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.66,869.4,
SCREW 6.5MM ASNIS 3 (100MM),890282,CDM,278,RC,C1713,HCPCS,both,,,553.34,415.01,,442.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.66,869.4,
SCREW LAG OMEGA 85MM,890013,CDM,278,RC,C1713,HCPCS,both,,,554,415.5,,443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.93,869.4,
VENOUS GRAFTS,5800194,CDM,480,RC,93455,HCPCS,outpatient,,,554,415.5,,443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,304.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.93,8687.74,
COLONOSCOPY THRU STOMA DIAGNOSTIC,6200080,CDM,360,RC,44388,HCPCS,outpatient,,,554,415.5,,443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,304.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,415.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,222.93,1622.75,
TOENAIL MATRIXECT,6200003,CDM,360,RC,11750,HCPCS,outpatient,,,555,416.25,,444,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,223.33,786.48,
EXCISION OF MALIGNANT LESION,6200010,CDM,510,RC,11622,HCPCS,outpatient,,,555,416.25,,444,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,223.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,444,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,223.33,1316.03,
SIMPLE ABSCESS,400001,CDM,361,RC,10060,HCPCS,outpatient,,,556,417,,444.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,444.8,
"Removal, non-biodegradable drug delivery",6100570,CDM,521,RC,11982,HCPCS,outpatient,,,556,417,,444.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.34,558.02,
"Removal with reinsertion, non-biodegrada",6100571,CDM,521,RC,11983,HCPCS,outpatient,,,556,417,,444.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.34,558.02,
PENTACEL VACCINE,6100448,CDM,250,RC,,,outpatient,,,193.5,145.13,,154.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.86,154.8,
I&D OF ABCESS-SIMPLE,6200347,CDM,510,RC,10060,HCPCS,outpatient,,,556,417,,444.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,444.8,
FHC-INC & DRAIN OF ABSCESS SIMPLE,6900001,CDM,982,RC,10060,HCPCS,outpatient,,,556,417,,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,333.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,159.07,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,99.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.19,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,65.58,333.6,
VISION EXAM,6900071,CDM,982,RC,99173,HCPCS,outpatient,,,556,417,,,,,,other,Not separately reimbursable for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,333.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,4.42,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,2.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,3.86,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1.59,333.6,
INCISION & DRAIN ABSCSS TECHNICAL FEE,7000042,CDM,761,RC,10060,HCPCS,outpatient,,,556,417,,444.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,305.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,444.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,444.8,
ALLERGEN PANEL,2800042,CDM,301,RC,86003,HCPCS,outpatient,,,557,417.75,,445.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,18.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2.61,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,306.35,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,6.79,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,8.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.83,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.61,445.6,
LACERATION SIMPLE: SCALP/NECK 2.6-7.5 CM,1400180,CDM,450,RC,12002,HCPCS,outpatient,,,558,418.5,,446.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,306.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,446.4,
LACERATION SIMPLE: SCALP/NECK 7.6-12.5CM,1400182,CDM,450,RC,12004,HCPCS,outpatient,,,558,418.5,,446.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,306.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,446.4,
LACERATION SIMPLE: UP TO 2.5CM,1400191,CDM,450,RC,12001,HCPCS,outpatient,,,558,418.5,,446.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,306.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,418.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,224.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,446.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,446.4,
SPLINTING:LONG ARM,1400193,CDM,450,RC,29105,HCPCS,outpatient,,,563,422.25,,450.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,450.4,
SPLINTING:SHORT LEG,1400195,CDM,450,RC,29515,HCPCS,outpatient,,,563,422.25,,450.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,450.4,
SPLINTING:LONG LEG,1400196,CDM,450,RC,29505,HCPCS,outpatient,,,563,422.25,,450.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,450.4,
ER STRAPPING UNNA BOOT,1400206,CDM,450,RC,29580,HCPCS,outpatient,,,563,422.25,,450.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,450.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.71,450.4,
VISTASEQ 12,2801112,CDM,301,RC,81406,HCPCS,outpatient,,,565,423.75,,452,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,603.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,603.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,141.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,310.75,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,367.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,367.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,367.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,367.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,367.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,367.74,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,282.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,282.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,282.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,452.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,282.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,424.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,141.44,603.38,
TEFLARO IV POWDER FOR SOLUTION 400MG,3203637,CDM,636,RC,J0712,HCPCS,both,,,565,423.75,,452,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,282.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,310.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,423.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.17,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.86,565,
DRAINAGE OF FINGER ABSCESS; COMPLICATED,6100708,CDM,521,RC,26011,HCPCS,outpatient,,,566,424.5,,452.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,311.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,227.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,227.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,452.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,424.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,227.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,452.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,227.76,2216.25,
BRONCHOSCOPY WITH BIOPSY,6200074,CDM,360,RC,31625,HCPCS,outpatient,,,567,425.25,,453.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,311.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,228.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,228.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,425.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,228.16,2362.57,
REPLACEMENT OF PEG TUBE,6200597,CDM,510,RC,43762,HCPCS,outpatient,,,568,426,,454.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,312.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,426,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,228.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.32,737.3,
OVERDOSE PANEL,2801440,CDM,301,RC,G0480,HCPCS,outpatient,,,570,427.5,,456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,170.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,57.21,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,313.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,148.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.43,100,,,fee schedule,100% UHC fee schedule for outpatient setting,114.43,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,183.08,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,114.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,171.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,57.21,456,
EVERCROSS DIL CATH EV3,5800070,CDM,270,RC,C1725,HCPCS,outpatient,,,570,427.5,,456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,285,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,229.37,456,
INCISION OF RECTAL ABSCESS,6000157,CDM,521,RC,46040,HCPCS,outpatient,,,570,427.5,,456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,313.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,229.37,3429.47,
INCISION OF RECTAL ABSCESS,6100531,CDM,521,RC,46040,HCPCS,outpatient,,,570,427.5,,456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,313.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,427.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,229.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,229.37,3429.47,
INTRAOPERATIVE COLONIC LAVAGE,6200198,CDM,360,RC,44701,HCPCS,outpatient,,,573,429.75,,458.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,286.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,230.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,458.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,230.58,458.4,
EXCISION BENIGN LESION 2.1 TO 3.0CM,6200380,CDM,360,RC,11443,HCPCS,outpatient,,,575,431.25,,460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,231.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,316.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,231.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,231.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,431.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,231.38,2216.25,
EMERGENCY ROOM LEVEL 5,6200006,CDM,510,RC,99285,HCPCS,outpatient,,,577,432.75,,461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,759.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,232.18,810.06,
INSERTION OF CHEST TUBE,6200020,CDM,510,RC,32551,HCPCS,outpatient,,,577,432.75,,461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,232.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,232.18,2198.94,
TEFLARO IV POWDER FOR SOLUTION 600MG,3203597,CDM,636,RC,J0712,HCPCS,both,,,582,436.5,,465.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.17,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.86,582,
I & D COMPLEX POSTOPERATIVE WOUND INF,6200183,CDM,360,RC,10180,HCPCS,outpatient,,,582,436.5,,465.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,320.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,436.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.2,3817.9,
PR RED CELL SEQUESTRATION,4410070,CDM,972,RC,7814026,HCPCS,outpatient,,,584,438,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,350.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,350.4,350.4,
EXC LESION 3.1CM TO 4.0CM,6200117,CDM,360,RC,11424,HCPCS,outpatient,,,584,438,,467.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,235,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,235,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,235,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,438,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,235,2843.72,
US VENOUS DOPPLER COMPLETE BILAT,4100034,CDM,921,RC,93970TC,HCPCS,outpatient,,,588,441,,470.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,236.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,294,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,294,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,294,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,323.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,236.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,236.61,470.4,
5 HIAA PLASMA,2801022,CDM,306,RC,82542,HCPCS,outpatient,,,589,441.75,,471.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,63.76,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12.04,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,323.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,31.32,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,471.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,471.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,441.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% UHC fee schedule for outpatient setting,24.09,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.13,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,471.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.04,471.2,
RABIES VACCINE,6900036,CDM,982,RC,90672,HCPCS,outpatient,,,592,444,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,355.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,44.46,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,27.79,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,38.91,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,27.79,355.2,
RABIES VACCINE INTRAMUSCULAR,6900220,CDM,982,RC,90675,HCPCS,outpatient,,,592,444,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,355.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,525.68,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,328.55,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,459.97,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,328.55,525.68,
VULVA LESION,6200513,CDM,360,RC,56440,HCPCS,outpatient,,,594,445.5,,475.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,326.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,239.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,475.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,445.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,475.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,475.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,239.03,4178.79,
DRAINAGE OF FINGER ABSCESS COMPLICATED,6200093,CDM,360,RC,26011,HCPCS,outpatient,,,595,446.25,,476,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,327.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,239.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,476,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,476,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,476,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,239.43,2216.25,
EXCISION OF MALIGNANT LESION TO FACE,6200153,CDM,360,RC,11642,HCPCS,outpatient,,,596,447,,476.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,327.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,239.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,239.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,447,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,239.83,1316.03,
REMOVAL OF INTRAUTERINE DEVICE,400129,CDM,361,RC,58301,HCPCS,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
CYSTIC FIBROSIS PROFILE DNA ANALYSIS,2800229,CDM,305,RC,81220,HCPCS,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1187.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1187.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1187.23,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,278.3,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,723.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,723.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,723.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,723.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,723.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,723.58,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,224.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.6,100,,,fee schedule,100% UHC fee schedule for outpatient setting,224.01,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,890.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,834.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,224.01,1187.23,
Tissue exam by pathologist,2800953,CDM,301,RC,88309,HCPCS,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,286.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,344.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,344.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,344.95,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,717.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,669.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,669.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,286.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,717.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,717.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,628.2,100,,,fee schedule,100% UHC fee schedule for outpatient setting,286.62,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1147.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,717.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1075.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,286.62,1147.63,
VISTASEQ 9,2801109,CDM,301,RC,81323,HCPCS,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,639.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,639.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,639.9,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,150,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,390,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,390,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,390,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,390,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,390,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,390,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,300,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,100,,,fee schedule,100% UHC fee schedule for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,480,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,300,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150,639.9,
CENTRAL VENOUS CATHETER,6200075,CDM,360,RC,36489,HCPCS,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
HEAD SURGERY PROCEDURE,6200179,CDM,360,RC,21499,HCPCS,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,480,
INSERT NON-TUNNELL CV CATH,6200351,CDM,510,RC,36556,HCPCS,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,4402.75,
INSERT NONTUNNEL CENT VENOUS CATH PROFES,7000045,CDM,982,RC,36556,HCPCS,outpatient,,,600,450,,,,,,other,Not separately reimbursable for physician setting,149.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,360,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,149.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,149.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,82.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,149.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,132.75,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,82.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.16,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.97,360,
SPINAL PUNCTURE; LUMBAR; DX; PRO FEE,7000048,CDM,982,RC,62270,HCPCS,outpatient,,,600,450,,,,,,other,Not separately reimbursable for physician setting,94.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,360,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,94.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.87,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,62.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,87.39,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.42,360,
PARACENTESIS ABD PRO FEE,7000049,CDM,982,RC,49082,HCPCS,outpatient,,,600,450,,,,,,other,Not separately reimbursable for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,360,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,113.68,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.47,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,360,
CORONARY STENT 3.5 1007849-08,90000441,CDM,278,RC,C1876,HCPCS,both,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,600,
VISTASEQ 11,2801111,CDM,301,RC,81405,HCPCS,outpatient,,,602,451.5,,481.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,642.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,642.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,642.78,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,150.67,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,331.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,391.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,391.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,391.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,391.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,391.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,391.76,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.16,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,301.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,452.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.67,642.78,
EGD REMOVAL TUMOR POLYP W/HOT BXFORCEPS,6200100,CDM,360,RC,43250,HCPCS,outpatient,,,602,451.5,,481.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,331.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,451.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,242.24,2573.96,
US ART DOP COMPLETE BILAT UPPER EXT,4100004,CDM,921,RC,93930TC,HCPCS,outpatient,,,603,452.25,,482.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,242.65,482.4,
US ARTERIAL DOPPLER UPPER EXT - BILATERA,4100047,CDM,921,RC,93930TC,HCPCS,outpatient,,,603,452.25,,482.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,242.65,482.4,
INITIAL OBSERVATION CARE-LEVEL 3,6200018,CDM,510,RC,99220,HCPCS,outpatient,,,603,452.25,,482.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,482.4,
REMOVAL OF FOREIGN BODY  HAND,6200394,CDM,360,RC,10121,HCPCS,outpatient,,,603,452.25,,482.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,331.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,452.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,482.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,242.65,4382.34,
EXCISION OF PILONDIAL CYST OR SINUS SIMP,6200155,CDM,360,RC,11770,HCPCS,outpatient,,,607,455.25,,485.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,244.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,333.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,244.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,244.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,485.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,455.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,485.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,485.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,244.26,3817.9,
COLONOSCOPY VIA STOMA W/BIOPSY,6200081,CDM,360,RC,44389,HCPCS,outpatient,,,610,457.5,,488,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,245.46,1622.75,
COLON VIA STOMA W/REMOVAL LESION SNARE,6200627,CDM,360,RC,44394,HCPCS,outpatient,,,610,457.5,,488,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,457.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,245.46,1622.75,
EXCIS BENIGN LESION-FACE <0.5,400035,CDM,360,RC,11440,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,959.13,
EXCIS BENIGN LESION-FACE 0.6-1.0,400037,CDM,360,RC,11441,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,959.13,
EXCIS BENIGN LESION-TRUCK EXTEM 0.6-1.0,400047,CDM,360,RC,11401,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,786.48,
EXCIS BENIGN LESION-TRUCK EXTEM 1.1-2.0,400048,CDM,360,RC,11402,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,959.13,
EXCIS BENIGN LESION-TRUNK EXTEM <0.5,400049,CDM,360,RC,11400,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,959.13,
EXCIS MAL LESION-FACE <0.5,400056,CDM,360,RC,11640,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,1316.03,
EXCIS MAL LESION-FACE 0.6-1.0,400058,CDM,360,RC,11641,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,1316.03,
EXCIS MAL LESION-FACE 1.1-2.0,400059,CDM,360,RC,11642,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,1316.03,
EXCIS MAL LESION-HEAD FEET GEN 0.6-1.0,400064,CDM,360,RC,11621,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,959.13,
EXCIS MAL LESION-TRUNK EXTEM 0.6-1.0,400070,CDM,360,RC,11601,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,959.13,
EXCIS MAL LESION-TRUNK EXTEM 1.1-2.0,400071,CDM,360,RC,11602,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,786.48,
CLOSURE OF A SPLIT WOUND,6200079,CDM,360,RC,12020,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,858.6,
LIGATION OF HEMORRHOIDS,6200574,CDM,360,RC,46221,HCPCS,outpatient,,,613,459.75,,490.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,490.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,246.67,1228.22,
MM MAMMOGRAM BX SPECIMEN,4001158,CDM,320,RC,76098TC,HCPCS,outpatient,,,615,461.25,,492,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,247.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,247.48,492,
XR URETHROGRAM-RETROGRADE,4000130,CDM,320,RC,74450TC,HCPCS,outpatient,,,616,462,,492.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,308,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,308,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,308,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.8,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,247.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,462,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,247.88,492.8,
EEG EXTENDED MORE THAN 1 HOUR,5600008,CDM,740,RC,95813,HCPCS,outpatient,,,618,463.5,,494.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,271.26,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,339.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,248.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,248.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,494.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,463.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,494.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,494.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.54,494.4,
PREOP NEEDLE LOC WIRE-FIRST LESION,4000019,CDM,360,RC,19282,HCPCS,outpatient,,,619,464.25,,495.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,249.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,495.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,495.2,
INTUBATION-RESPIRATORY,5200049,CDM,410,RC,31500,HCPCS,outpatient,,,621,465.75,,496.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,341.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,249.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,249.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,496.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,465.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,496.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,496.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,496.8,
PREOP NEEDLE LOC WIRE-ADDITIONAL LESION,4000018,CDM,360,RC,19282,HCPCS,outpatient,,,623,467.25,,498.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,498.4,
CARDIOPULMONARY RESUSCITATION NOS,6200467,CDM,360,RC,92950,HCPCS,outpatient,,,623,467.25,,498.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,467.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,498.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.54,498.4,
CLOASURE OF WOUND,6200078,CDM,360,RC,12032,HCPCS,outpatient,,,626,469.5,,500.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,251.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,344.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,469.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,251.9,718.61,
DESTRUCTION 15 OR MORE LESIONS,6900012,CDM,982,RC,17004,HCPCS,outpatient,,,626,469.5,,,,,,other,Not separately reimbursable for physician setting,104.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,375.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,94.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,94.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,104.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,104.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,94.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,94.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,104.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,151.79,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,94.87,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,132.82,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,94.87,375.6,
DIAGNOSTIC SIGMOIDOSCOPY,6100535,CDM,521,RC,45330,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,892.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,716.75,1228.22,
BRONCHOSCOPY W/FB REMOVAL,6200073,CDM,360,RC,31635,HCPCS,outpatient,,,630,472.5,,504,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,346.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,253.51,2362.57,
EXCISION MAL LESION 2.1 TO 3,6200382,CDM,360,RC,11603,HCPCS,outpatient,,,635,476.25,,508,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,476.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,255.52,1316.03,
ASPIRATION/INJECTION MEDIUM JOINT BURSA,1400012,CDM,450,RC,20605,HCPCS,outpatient,,,636,477,,508.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,508.8,
ASPIRATION/INJECTION LARGE JOINT BURSA,1400013,CDM,450,RC,20610,HCPCS,outpatient,,,636,477,,508.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,508.8,
ASPIRATION/INJECTION SMALL JOINT BURSA,1400014,CDM,450,RC,20600,HCPCS,outpatient,,,636,477,,508.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,508.8,
Aspiration and/or injection of ganglion,6100572,CDM,521,RC,20612,HCPCS,outpatient,,,636,477,,508.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,255.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,508.8,
ER INJ ANESTHETIC  FACIAL NERVE,1400106,CDM,450,RC,64999,HCPCS,outpatient,,,637,477.75,,509.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,350.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,509.6,
ER INJ SING/MULT TRIGGER PTS 3+ MUSCLE,1400107,CDM,450,RC,20553,HCPCS,outpatient,,,637,477.75,,509.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,350.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,509.6,
ER INJ SING/MULT TRIGGER PTS 1-2 MUSCLE,1400108,CDM,450,RC,20552,HCPCS,outpatient,,,637,477.75,,509.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,350.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,509.6,
INJECTION LIGAMENT TENDON TRIGGER POINTS,1400264,CDM,450,RC,20550,HCPCS,outpatient,,,637,477.75,,509.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,350.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,234.5,509.6,
INJ SINGLE TENDON SHEATH/LIGAMENT,6900015,CDM,982,RC,20550,HCPCS,outpatient,,,637,477.75,,,,,,other,Not separately reimbursable for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,382.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,38.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,38.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,38.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,61.58,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,38.49,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,53.89,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36.24,382.2,
INJ TRIGGER POINT 1 OR 2 MUSCLES,6900016,CDM,982,RC,20552,HCPCS,outpatient,,,637,477.75,,,,,,other,Not separately reimbursable for physician setting,32.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,382.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,32.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,32.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,36.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,32.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,57.84,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,36.15,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,50.61,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,32.31,382.2,
INTERMEDIAT JOINT OR BURSA,6900017,CDM,982,RC,20605,HCPCS,outpatient,,,637,477.75,,,,,,other,Not separately reimbursable for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.41,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,382.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.41,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.41,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.41,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,36.41,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36.41,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,58.26,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,36.41,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,50.97,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36.24,382.2,
JOINT INJECTION,6900018,CDM,982,RC,20610,HCPCS,outpatient,,,637,477.75,,,,,,other,Not separately reimbursable for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,382.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,46.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,70.69,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,44.18,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,61.85,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,44.18,382.2,
ASPIRATION/INJECTION OF GANGLIONYST,6900019,CDM,982,RC,20612,HCPCS,outpatient,,,637,477.75,,,,,,other,Not separately reimbursable for physician setting,36.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,40.06,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,382.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,40.06,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,40.06,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,40.06,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,36.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,36.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,40.06,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,40.06,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,36.31,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,64.1,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,40.06,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,56.08,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,36.31,382.2,
INJ RETROGRADE URETHOCYSTOGRAPHY,4000012,CDM,360,RC,51610,HCPCS,outpatient,,,640,480,,512,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,128.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,128.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.07,512,
CIRCUMCISION; NOT NEWBORN,6200328,CDM,510,RC,54161,HCPCS,outpatient,,,644,483,,515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,259.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,354.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,259.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,259.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,483,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,259.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,259.15,3748.83,
REM FOREIGN BODY INTRANASAL W/ANESTH,6200400,CDM,450,RC,30310,HCPCS,outpatient,,,646,484.5,,516.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,259.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,355.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,259.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,259.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,484.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,516.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4204.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,516.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,259.95,4204.78,
REPAIR 2.6CM TO 7.5CM NECK HAND FEET EXT,6200261,CDM,360,RC,12042,HCPCS,outpatient,,,647,485.25,,517.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,260.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,355.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,260.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,260.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,517.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,485.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,517.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,260.35,718.61,
INTERNAL MAM INJ,5800092,CDM,480,RC,93459,HCPCS,outpatient,,,650,487.5,,520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,357.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,261.56,8687.74,
BRONCH WITH WASHINGS,6200071,CDM,360,RC,31624,HCPCS,outpatient,,,650,487.5,,520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,357.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,261.56,2362.57,
LYSIS PENILE POST CIRCUMCISION ADHESIONS,6200446,CDM,360,RC,54162,HCPCS,outpatient,,,651,488.25,,520.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,358.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,261.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,261.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,520.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,488.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,520.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,520.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,261.96,3748.83,
NM THYROID TC 99M UPTAKE AND IMAGING,4400062,CDM,341,RC,78014,HCPCS,outpatient,,,656,492,,524.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,263.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,433.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,433.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,433.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360.8,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,263.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,492,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,263.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,538.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,524.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,263.97,603.39,
Negative Pressure Therapy <50 sq cm,65097607,CDM,510,RC,97607,HCPCS,outpatient,,,657,492.75,,525.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,295.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,295.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,295.93,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,361.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,264.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,492.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,264.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,264.38,551.37,
INITIAL HOSPITAL CARE-ADMIT LEVEL 2,6200011,CDM,510,RC,99223,HCPCS,outpatient,,,658,493.5,,526.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,264.78,526.4,
INITIAL INPATIENT CONSULT-LEVEL 3,6200016,CDM,510,RC,99253,HCPCS,outpatient,,,658,493.5,,526.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,329,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,493.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,264.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,264.78,526.4,
REPAIR WOUND 2.6CM TO 5.0CM,6200276,CDM,360,RC,12052,HCPCS,outpatient,,,660,495,,528,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,363,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,265.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,265.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,528,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,495,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,528,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,528,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,265.58,718.61,
CHEST TUBE/NO THORACENTESIS,5800053,CDM,480,RC,32551,HCPCS,outpatient,,,662,496.5,,529.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,364.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,266.39,2198.94,
PARACENTESIS INIT SURG,5800122,CDM,982,RC,49082,HCPCS,outpatient,,,662,496.5,,,,,,other,Not separately reimbursable for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,397.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,106.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,113.68,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,71.05,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.47,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,71.05,397.2,
PERCARDOCENTESIS,5800125,CDM,480,RC,33010,HCPCS,outpatient,,,662,496.5,,529.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,331,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,364.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,266.39,529.6,
INSERTION OF INTRAUTERINE DEVICE (IUD),6900228,CDM,982,RC,58300,HCPCS,outpatient,,,668,501,,,,,,other,Not separately reimbursable for physician setting,50.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,400.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,49.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,49.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,50.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,50.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,49.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,50.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,79.47,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,49.67,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,69.54,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,49.67,400.8,
REMOVAL OF INTRAUTERINE DEVICE,6900229,CDM,982,RC,58301,HCPCS,outpatient,,,668,501,,,,,,other,Not separately reimbursable for physician setting,62.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,400.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,65.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,62.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,65.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,65.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,105.01,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,65.63,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,91.88,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,62.38,400.8,
INC & DRAINAGE OF VULVA  OR PERINEAL ABS,6900233,CDM,982,RC,56405,HCPCS,outpatient,,,668,501,,,,,,other,Not separately reimbursable for physician setting,69.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,122.22,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,400.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,122.22,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,122.22,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,122.22,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,69.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,69.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,122.22,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,122.22,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,69.4,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,195.55,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,122.22,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,171.11,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,69.4,400.8,
PREMARIN PER 25 MG,6900113,CDM,982,RC,J1410,HCPCS,outpatient,,,670,502.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,372.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,402,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,372.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,372.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,372.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,372.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,372.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,595.97,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,372.48,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,521.47,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,372.48,595.97,
SKIN & SUBQ CLOSURE NEC,6200288,CDM,360,RC,12034,HCPCS,outpatient,,,673,504.75,,538.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,370.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,270.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,270.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,538.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,504.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,538.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,538.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,270.82,718.61,
INJ SHOULDER ARTHROGRAPHY,4000013,CDM,360,RC,23350,HCPCS,outpatient,,,680,510,,544,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,184.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,184.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,184.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,510,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,184.72,544,
PLEURX INSERT CHEST TUBE,6200621,CDM,360,RC,32550,HCPCS,outpatient,,,681,510.75,,544.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6231.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6231.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6231.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,374.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,274.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,274.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,544.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,544.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,544.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,274.03,6231.87,
NM MUGA FIRST PASS,4400023,CDM,341,RC,78496TC,HCPCS,outpatient,,,683,512.25,,546.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,341.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,512.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,274.84,546.4,
"Laparoscopy, surgical, with vaginal hyst",6100574,CDM,521,RC,58552,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,13430.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,7837.6,13430.53,
PR BX LYMPH-CER/ING/AXILLARY,4011137,CDM,972,RC,38505,HCPCS,outpatient,,,688,516,,,,,,other,Not separately reimbursable for physician setting,79.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.62,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,412.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.62,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.62,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,83.62,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,79.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,79.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.62,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,83.62,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,79.26,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,133.79,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,83.62,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,117.07,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,79.26,412.8,
NM LUNG PERFUSION MULPITLE PROJECTION,4400019,CDM,341,RC,78580TC,HCPCS,outpatient,,,689,516.75,,551.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,551.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,516.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,551.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,551.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,277.25,551.2,
BREAST NEEDLE BIOPSY,400007,CDM,361,RC,19100,HCPCS,outpatient,,,690,517.5,,552,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,379.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,277.66,2216.25,
INSERTION INTRAUTERINE DEVICE,400091,CDM,361,RC,58300,HCPCS,outpatient,,,690,517.5,,552,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,277.66,552,
CPR,1400050,CDM,450,RC,92950,HCPCS,outpatient,,,690,517.5,,552,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,379.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.54,552,
INTUBATION ENDOTRACHEAL,1400071,CDM,450,RC,31500,HCPCS,outpatient,,,690,517.5,,552,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,379.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,552,
EXC MALIG LESION 2.1CM TO 3.0CM,6200122,CDM,360,RC,11623,HCPCS,outpatient,,,690,517.5,,552,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,379.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,517.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,552,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,277.66,2843.72,
LIGATION OR BIOPSY TEMPORAL ARTERY,6200205,CDM,360,RC,37609,HCPCS,outpatient,,,691,518.25,,552.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,278.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,552.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,518.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,552.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,278.06,2843.72,
MONSEL'S SOLUTION,6100663,CDM,250,RC,,,outpatient,,,48,36,,38.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.32,38.4,
P F T  BASIC PRE P P,5200060,CDM,460,RC,94060,HCPCS,outpatient,,,692,519,,553.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,146.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.06,553.6,
STRESS TEST MEDICATED,5500002,CDM,482,RC,93017,HCPCS,outpatient,,,692,519,,553.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,379.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,379.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.91,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.54,553.6,
"OP UPPER GI REM TUMOR,LESION W/SNARE",6200421,CDM,360,RC,43251,HCPCS,outpatient,,,692,519,,553.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,380.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,519,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,278.46,2573.96,
CARDIOVERSION OP,5200020,CDM,480,RC,92960,HCPCS,outpatient,,,694,520.5,,555.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,381.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,279.27,1042.65,
CL CARDIOVERSION ELECTIVE,5800055,CDM,480,RC,92960,HCPCS,outpatient,,,694,520.5,,555.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,381.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,520.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,555.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,279.27,1042.65,
ER CLO TX HUMERAL GR TUB FX WO MANIP,1400029,CDM,450,RC,23620,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
ER CLO TX HUMERAL SHAFT FX WO MANIP,1400030,CDM,450,RC,24500,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
ER CLO TX PROX HUMERAL FX WO MANIP,1400036,CDM,450,RC,23600,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
GI COCKTAIL,6100672,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
ER CLO TX RADIAL HEAD SUBLUX-CHILD,1400037,CDM,450,RC,24640,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
CLONIDINE 0.2MG TAB,6100674,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
BENTYL ELIXIR 10MG/5ML,6100675,CDM,250,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
XYLOCAINE VISC,6100676,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
MAALOX 30ML LIQUID,6100677,CDM,637,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
TETRACAINE EYE DROPS,6100678,CDM,250,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
ER CLO TX SCAPULAR FX WO MANIPULATION,1400042,CDM,450,RC,23570,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
ER CLO TX ULNAR FX PROXIMAL WO MANIPULA,1400044,CDM,450,RC,24670,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
ER DRAIN ABSCESS/CYST/HEMATOMA ORAL CAV,1400064,CDM,450,RC,41800,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,559.2,
REPLACEMENT TRACHEAL TUBE,1400072,CDM,450,RC,31502,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,424.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,424.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,424.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,559.2,
NASAL HEMORRHAGE:POSTERIOR PACKING,1400073,CDM,450,RC,30905,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,559.2,
FBR:INTRANASAL,1400082,CDM,450,RC,30300,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,559.2,
FBR:CONJUN  SUPERFICIAL,1400085,CDM,450,RC,65205,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,234.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,559.2,
I&D ABSCESS CYST SIMPLE,1400094,CDM,450,RC,10060,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,559.2,
ER I&D BARTHOLIN CYST,1400095,CDM,450,RC,56420,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,263.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,164.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,246.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,153.63,559.2,
ER I&D SEBACEOUS CYST,1400099,CDM,450,RC,10060,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,559.2,
ER INCIS/DRAIN VULVA/PERINEAL ABCESS,1400103,CDM,450,RC,56405,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,251.8,559.2,
NASAL HEMMORRHAGE:SIMPLE ANTERIOR,1400152,CDM,450,RC,30901,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,559.2,
ER REP LAC MOUTH 2.5 OR LESS,1400171,CDM,450,RC,40830,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,559.2,
ER UNLISTED PROCEDURE ORAL CAVITY,1400216,CDM,450,RC,41899,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,559.2,
NASAL HEMORRHAGE:ANTERIOR COMPLEX,1400268,CDM,450,RC,30903,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,232.09,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,171.59,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.14,559.2,
ANKLE DISLOCATION:WO ANESTHESIA,1400269,CDM,450,RC,27840,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
TOE IPJ DISLOCATION,1400273,CDM,450,RC,28660,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
TREATMENT FRACTURE UPPER ARM/ELBOW WO MP,1400286,CDM,450,RC,24530,HCPCS,outpatient,,,699,524.25,,559.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,559.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,559.2,
INCISION/REMOVAL FOREIGN BODY SIMPLE,400087,CDM,361,RC,10120,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,718.61,
ER ASPIRATION OF ABSCESS SIMPLE,1400015,CDM,450,RC,10160,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,560,
ER CLO TX A/C DISLOCATION WO MANIP,1400024,CDM,450,RC,23540,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,560,
ER CLO TX CLAVICULAR FX WO MANIP,1400025,CDM,450,RC,23500,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,560,
ER CLO TX DISTAL FIBULAR FX WO MANIPULA,1400026,CDM,450,RC,27786,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,560,
SMALL BURN DRSG/DEBRIDEMENT:WO ANESTHESI,1400069,CDM,450,RC,16020,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,560,
LACERATION INTERMEDIATE FACE 5.1-7.5 CM,1400131,CDM,450,RC,12053,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,560,
LAC INTERM: N/H/F/EG 2.25 CM OR LESS,1400139,CDM,450,RC,12041,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,560,
ARTHROCENTESIS ASPRTN/INJ SMALL JNT/BRSA,6100713,CDM,510,RC,20600,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
ER TX SUPERFICIAL WOUND SIMPLE,1400213,CDM,450,RC,12020,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,858.6,
EXPLORE CHEST WOUND,6200418,CDM,360,RC,20101,HCPCS,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,3449.93,
CHROMOSOME ANALYSIS 15-20 CELLS,2800164,CDM,311,RC,88262,HCPCS,outpatient,,,702,526.5,,561.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,528.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,528.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,528.71,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,62.74,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,386.1,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,163.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,163.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,163.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,163.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,163.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,163.14,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,125.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.49,100,,,fee schedule,100% UHC fee schedule for outpatient setting,125.49,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,200.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,188.23,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,62.74,561.6,
EXC MALIG LESION 3.1 TO 4.0 CM,6200123,CDM,360,RC,11604,HCPCS,outpatient,,,702,526.5,,561.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,282.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,282.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,282.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,561.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,282.48,1316.03,
Excision Endocervical Curettage,6900239,CDM,982,RC,57505,HCPCS,outpatient,,,702,526.5,,,,,,other,Not separately reimbursable for physician setting,64.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,104.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,421.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,104.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,104.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,104.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,64.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,104.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,104.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.13,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,167.02,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,104.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,146.15,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,64.13,421.2,
Excision of vaginal cyst or tumor,6900243,CDM,982,RC,57135,HCPCS,outpatient,,,702,526.5,,,,,,other,Not separately reimbursable for physician setting,124.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,183.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,421.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,183.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,183.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,183.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,124.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,124.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,183.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,183.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,124.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,293.36,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,183.35,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,256.69,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,124.41,421.2,
DRAINAGE OF SCROTUM,6200507,CDM,360,RC,54700,HCPCS,outpatient,,,704,528,,563.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,387.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,283.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,528,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,563.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,283.29,4427.19,
OBSERVATION HOSPITAL SAME DAY CARE,6200218,CDM,360,RC,99236,HCPCS,outpatient,,,706,529.5,,564.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,284.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,284.09,564.8,
OPERATIVE UPPER GI ENDOSCOPY,6200444,CDM,360,RC,43255,HCPCS,outpatient,,,709,531.75,,567.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,285.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,389.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,285.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,285.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,567.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,567.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,567.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,285.3,2573.96,
US CAROTID DOPPLER COMPLETE BIL,4100010,CDM,921,RC,93880,HCPCS,outpatient,,,711,533.25,,568.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,286.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,389.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,389.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,389.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,391.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,286.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,568.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,533.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,568.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,286.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,568.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.4,568.8,
BIOPSY BONE OPEN SUPERFICIAL,6200520,CDM,360,RC,20240,HCPCS,outpatient,,,713,534.75,,570.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,286.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,392.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,286.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,570.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,534.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,286.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,570.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,286.91,3817.9,
DILATION AND CURETTAGE,6200508,CDM,360,RC,58120,HCPCS,outpatient,,,716,537,,572.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3223.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,572.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,288.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,572.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,572.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,572.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,572.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,288.12,4178.79,
IMAGE CATH FLUID PERI/RE,6200509,CDM,360,RC,49406,HCPCS,outpatient,,,717,537.75,,573.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3897.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3897.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3897.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,394.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,288.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,288.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,537.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,288.52,3897.27,
SCREW 6.5 CANN 70MM,890227,CDM,278,RC,C1713,HCPCS,both,,,718.4,538.8,,574.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,289.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,574.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,289.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,574.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,574.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,289.08,869.4,
REMOVAL OF TCV CATH W/O PORT OR PUMP,6200253,CDM,360,RC,36589,HCPCS,outpatient,,,720,540,,576,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,289.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,396,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,289.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,289.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,540,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,289.73,1560.65,
REPLACE TUNNELED CV CATH ONLY,6200279,CDM,360,RC,36578,HCPCS,outpatient,,,723,542.25,,578.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,290.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,397.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,578.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,290.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,290.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,578.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,542.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,578.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,578.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,290.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,578.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,290.94,4402.75,
REMOVE BY LIGATION INTERNAL HEMORRHOIDS,6200576,CDM,360,RC,46945,HCPCS,outpatient,,,725,543.75,,580,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,291.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,398.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,291.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,291.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,580,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,543.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,580,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,291.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,580,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,291.74,3797.53,
PLATE 5 HOLE COMPRESSION (629545S),890073,CDM,278,RC,C1713,HCPCS,both,,,728,546,,582.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,292.95,869.4,
Methylene Blue 1% 5mg/ml 10 ml,3201107,CDM,636,RC,Q9968,HCPCS,both,,,728,546,,582.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,364,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11.23,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.49,728,
REMOVE BY LIGAT INTERNAL HEMORRHOIDS,6200550,CDM,510,RC,46946,HCPCS,outpatient,,,730,547.5,,584,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,293.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3024.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,401.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,293.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,293.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,584,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,547.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,293.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,584,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,293.75,3797.53,
OPEN INCISIONAL BX OF BREAST,6200221,CDM,360,RC,19101,HCPCS,outpatient,,,732,549,,585.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,402.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,585.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,294.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,294.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,585.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,549,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,585.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,585.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,585.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,294.56,5080.87,
ER FORESKIN MANIPULATION,1400089,CDM,450,RC,54450,HCPCS,outpatient,,,734,550.5,,587.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,495.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,495.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,495.29,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,403.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,295.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,295.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,295.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.32,587.2,
HIV GENOSURE,2800354,CDM,301,RC,87900,HCPCS,outpatient,,,734,550.5,,587.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,388.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,388.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,388.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,65.17,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,403.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,169.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,169.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,169.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,169.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,169.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,169.46,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,130.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,130.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,130.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,550.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.35,100,,,fee schedule,100% UHC fee schedule for outpatient setting,130.35,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,208.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,130.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,195.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,65.17,587.2,
VASECTOMY,6200315,CDM,360,RC,55250,HCPCS,outpatient,,,735,551.25,,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,295.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,295.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,588,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,551.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,295.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,588,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,295.76,4427.19,
EXC LESION 3.1 TO 4.0 CM,6200116,CDM,360,RC,11444,HCPCS,outpatient,,,738,553.5,,590.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,405.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,296.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,296.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,590.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,590.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,590.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,296.97,2216.25,
COVID VAC PFIZER BIVLT GRAY CAP 12>OLDER,6100741,CDM,636,RC,91312,HCPCS,both,,,0.01,0.01,,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,0.01,
COLONOSCOPY W/TUMOR REMOVAL BY HOT FRCEP,6100505,CDM,521,RC,45384,HCPCS,outpatient,,,740,555,,592,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,297.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,407,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,297.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,297.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,297.78,1622.75,
MOST RECENT HbA1c 7.0%-7.9% (DM),6100760,CDM,521,RC,3051F,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,0.01,0.01,
MOST RECENT HbA1c 8.0%-8.9% (DM),6100761,CDM,521,RC,3052F,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,0.01,0.01,
REMOVE RECTAL OBSTUCTION,6200428,CDM,510,RC,45915,HCPCS,outpatient,,,741,555.75,,592.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,407.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,298.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,298.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,592.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,298.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,592.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,298.18,1600.47,
PITRESSIN 20 U/mL  1 ml,3200671,CDM,636,RC,J2598,HCPCS,both,,,742.59,556.94,,594.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,371.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,371.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,371.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408.42,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,594.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,298.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,298.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,594.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,594.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,594.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,298.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,594.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,298.82,742.59,
US ART DOP COMPLETE BILAT LOWER EXT,4100003,CDM,921,RC,93925TC,HCPCS,outpatient,,,748,561,,598.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301,598.4,
"STRENGER TEST, SPEECH",5100631,CDM,440,RC,92577GN,HCPCS,outpatient,,,748,561,,598.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,60,100,,,case rate,100% Coventry therapy case rate for outpatient setting,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,561,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60,598.4,
EGD W/DIAGNOSTIC BRUSH,6100509,CDM,982,RC,43235,HCPCS,outpatient,,,750,562.5,,,,,,other,Not separately reimbursable for physician setting,183.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,118.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,450,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,118.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,118.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,118.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,183.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,183.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,118.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,118.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,183.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,188.82,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,118.01,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,165.21,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,118.01,450,
EGD WITH REMOVAL FOREIGN BODY,6200101,CDM,360,RC,43247,HCPCS,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,1529.37,
DIAGNOSTIC COLONOSCOPY,6200336,CDM,510,RC,45378,HCPCS,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,1622.75,
UNLISTED PROCEDURE ADB,6200398,CDM,360,RC,22999,HCPCS,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,786.48,
NAIL REMOVAL,6111730,CDM,521,RC,11730,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,266.88,
CA SCREENING COLONOSCOPY,6200423,CDM,510,RC,G0121,HCPCS,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,1228.22,
"CRYOSURGERY, 1.1 TO 2.0",6117262,CDM,521,RC,17262,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,309.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,309.77,
CYSTOSCOPE,6152000,CDM,521,RC,52000,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,1315.59,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1315.59,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1315.59,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,577.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,539.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,539.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,539.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,577.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,577.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,924.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,577.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,539.34,1315.59,
CYSTOSCOPE AND TREATMENT,6152332,CDM,521,RC,52332,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,4425,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4425,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4425,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,4736.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,2764.35,4736.99,
TOTAL HYST W/T/O 250G OR LESS,6158571,CDM,521,RC,58571,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,9239.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9239.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9239.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,13430.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,7837.6,13430.53,
TYMPANOMETRY,6192567,CDM,521,RC,92567,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,85.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,85.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,50.19,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,31.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,29.28,85.75,
RAPID COVID ANTIGEN NELHC,6199011,CDM,300,RC,87426,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,17.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.99,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.66,56.52,
CA SCREENING COLONOSCOPY HIGH RISK,6200424,CDM,510,RC,G0105,HCPCS,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,1228.22,
BLOOD/LYMPH SYSTEM PROCEDURE UNLISTED,6200583,CDM,360,RC,38999,HCPCS,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,602.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,690.5,
EXC MALIG FACIAL LESION 2.1 TO 3.0CM,6200121,CDM,360,RC,11643,HCPCS,outpatient,,,751,563.25,,600.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,413.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,302.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,302.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,600.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,302.2,2216.25,
EMERGENCY TRACHEOTOMY,6200102,CDM,360,RC,31603,HCPCS,outpatient,,,753,564.75,,602.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,414.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,303.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,303.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,602.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,602.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,602.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,303.01,2051.58,
PLACEMENT OF SETON,6200233,CDM,360,RC,46020,HCPCS,outpatient,,,762,571.5,,609.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,419.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,306.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,306.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,571.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,306.63,4526.47,
VISTASEQ 2,2801102,CDM,301,RC,81295,HCPCS,outpatient,,,764,573,,611.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,307.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,814.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,814.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,814.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,190.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,420.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,496.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,496.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,496.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,496.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,496.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,496.21,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,381.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,381.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,307.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,381.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,573,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381.7,100,,,fee schedule,100% UHC fee schedule for outpatient setting,307.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,610.72,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,381.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,572.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,190.85,814.17,
ANKLE ARTHROGRAPHY,4000007,CDM,360,RC,73615TC,HCPCS,outpatient,,,765,573.75,,612,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,307.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,382.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,382.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,382.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,307.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,573.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,307.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,307.84,612,
NM PARATHYROID IMAG*,4000215,CDM,341,RC,78070,HCPCS,outpatient,,,768,576,,614.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,362.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,362.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,538.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,309.04,614.4,
INJECTION JOINT  WITH CONTRAST,4200068,CDM,320,RC,23350,HCPCS,outpatient,,,768,576,,614.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,184.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,184.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,184.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,184.72,614.4,
DO NOT USE,4400024,CDM,341,RC,78071,HCPCS,outpatient,,,768,576,,614.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,603.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,603.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,538.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,309.04,614.4,
NM THYROID I 123 UPTAKE SINGLE OR MULTIP,4400061,CDM,341,RC,78012,HCPCS,outpatient,,,768,576,,614.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,145.92,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,576,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,309.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,538.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.92,614.4,
SFMC CPT HBV GENOTYPE CHARGE ONLY,2801393,CDM,306,RC,87912,HCPCS,outpatient,,,772.35,579.26,,617.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,754.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,754.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,754.83,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,424.79,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,617.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,579.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,617.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,579.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,617.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,411.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,617.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.72,754.83,
"DEBR OF SKIN,SUBC TISSUE,MUSCLE &BONE",6200083,CDM,360,RC,11044,HCPCS,outpatient,,,774,580.5,,619.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,425.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,311.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,311.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,580.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,311.46,3001.14,
EXC LESION TONGUE W/CLSR POSTERIOR 1/3RD,6200625,CDM,360,RC,41113,HCPCS,outpatient,,,775,581.25,,620,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,426.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4204.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,311.86,4204.78,
PARTIAL REMOVAL DISTAL END TOE,6200626,CDM,360,RC,28153,HCPCS,outpatient,,,775,581.25,,620,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,426.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,581.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,311.86,4399.33,
SPEED GUIDE (703888),890098,CDM,278,RC,C1713,HCPCS,both,,,775.2,581.4,,620.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,542.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,620.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,311.94,869.4,
REMOVAL SWEAT GLAND LESION,6200256,CDM,360,RC,11462,HCPCS,outpatient,,,779,584.25,,623.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,428.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,313.47,3817.9,
I&D ABSCESS SUBFASCIAL,6200577,CDM,360,RC,20005,HCPCS,outpatient,,,779,584.25,,623.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,389.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,389.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,389.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,584.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,313.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,313.47,623.2,
NM THYR RADIOPHAR. ORAL THERAPY,4400060,CDM,342,RC,79005TC,HCPCS,outpatient,,,784,588,,627.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,392,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,392,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,392,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.2,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,315.48,627.2,
EXCISION LESION 3.1CM TO 4.0CM,6200144,CDM,360,RC,11624,HCPCS,outpatient,,,784,588,,627.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,431.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,588,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,315.48,2843.72,
CHEMO ADMIN INTRAVENENOUS INFUSION 1HR,1696413,CDM,335,RC,96413,HCPCS,outpatient,,,785,588.75,,628,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,422.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,422.75,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,431.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,491.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,307.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,460.86,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,286.87,628,
EPOGEN 20000 (PROCRIT),3200293,CDM,636,RC,J0885,HCPCS,both,,,785,588.75,,628,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,392.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,392.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,392.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,431.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,588.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,785,
I&D COMPLEX ABCESS,400086,CDM,361,RC,10061,HCPCS,outpatient,,,786,589.5,,628.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,432.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,316.29,727.27,
I&D OF ABCESS-COMPLICATED,6200346,CDM,510,RC,10061,HCPCS,outpatient,,,786,589.5,,628.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,432.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,589.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,316.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,628.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,316.29,727.27,
ESOPHAGEAL (DILATA),400034,CDM,490,RC,43450,HCPCS,outpatient,,,791,593.25,,632.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1004.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1004.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1004.32,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,593.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,349.65,1220.05,
XR METASTATIC SERIES/EXTREMITIES COMP,4000092,CDM,320,RC,77075TC,HCPCS,outpatient,,,795,596.25,,636,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,397.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,397.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,397.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,319.91,636,
XR METASTATIC SERIES/W/O EXTREMITIES,4000093,CDM,320,RC,77074TC,HCPCS,outpatient,,,795,596.25,,636,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,397.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,397.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,397.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,319.91,636,
EXC SOFT TISSUE LESION EXTERNAL AUD CANL,6200129,CDM,360,RC,69145,HCPCS,outpatient,,,795,596.25,,636,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,437.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,596.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,636,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,319.91,3817.9,
PR CT GUID NEEDLE PLCM (BX ASP INJ) SURG,4310019,CDM,972,RC,77012,HCPCS,outpatient,,,797,597.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,478.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,64.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,64.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,64.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.74,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,64.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,89.89,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,64.21,478.2,
CRYOTHERAPY,400024,CDM,361,RC,57511,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,251.8,640,
LACERATION INTERMEDIATE: SKIN 2.6-7.5 CM,1400126,CDM,450,RC,12032,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,718.61,
LACERATION INTERMEDIATE:FACE 7.6-12.5 CM,1400133,CDM,450,RC,12034,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,718.61,
LACERATION INTERMEDIATE:SKIN UP TO 2.5CM,1400138,CDM,450,RC,12031,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,718.61,
KNEE ARTHROGRAPHY,4000010,CDM,360,RC,73580TC,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,640,
STENT COBALT CHROMIUM CORONARY,5890128,CDM,278,RC,C1876,HCPCS,both,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,800,
DIAG LAPARO SEPARATE PRO,6100101,CDM,521,RC,49320,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,7703.27,
LAPARO PROC  ABDM/PER/OMENT,6100103,CDM,521,RC,49329,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,7703.27,
REPAIR OF VAGINIA,6100118,CDM,521,RC,57200,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,4178.79,
AMPUTATION OF CERVIX,6100135,CDM,521,RC,57540,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,800,
REMOVAL OF RESIDUAL CERVIX,6100136,CDM,521,RC,57550,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,6850.42,
REVISION OF CERVIX,6100138,CDM,521,RC,57720,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,4178.79,
CL-BUPIVICAINE HC1 30ML,6200042,CDM,636,RC,,,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
MYOMECTOMY ABDOM METHOD,6100142,CDM,521,RC,58140,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5166.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5166.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5166.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,5166.92,
CL-KENALOG PER 10MG 1CC,6200044,CDM,636,RC,,,both,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,25,
MYOMECTOMY ABDOM COMPLEX,6100143,CDM,521,RC,58146,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3319.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3319.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3319.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,3319.26,
SUSPENSION OF UTERUS,6100152,CDM,521,RC,58400,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3788.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3788.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3788.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,3788.9,
OCCLUDE FALLOPIAN TUBE,6100154,CDM,521,RC,58615,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,4178.79,
LAPAROSCOPY LYSIS,6100155,CDM,521,RC,58660,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,8162.33,
LAPAROSCOPY  TUBAL CAUTE,6100158,CDM,521,RC,58670,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,8162.33,
REPAIR OVIDUCT,6100160,CDM,521,RC,58750,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,800,
REMOVAL OF OVARY(S),6100162,CDM,521,RC,58940,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5532.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5532.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5532.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,5532.88,
LESION REMOVAL COLONOSCOPY,6200465,CDM,360,RC,45383,HCPCS,outpatient,,,800,600,,640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.92,640,
BIOPSY ARM ELBOW SOFT TISSUE,6200561,CDM,360,RC,24065,HCPCS,outpatient,,,805,603.75,,644,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,323.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,442.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,644,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,323.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,644,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,644,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,644,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,323.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,644,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,323.93,2843.72,
NM LEXISCAN 0.4 mg/5ml,4400036,CDM,636,RC,J2785,HCPCS,both,,,807,605.25,,645.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,403.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,403.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,403.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,324.74,807,
EXCISION BEN LESION >4.0,6200137,CDM,360,RC,11406,HCPCS,outpatient,,,808,606,,646.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,325.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,325.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,646.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,606,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,646.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,646.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,325.14,2843.72,
Y PLATE,890081,CDM,278,RC,C1713,HCPCS,both,,,809.5,607.13,,647.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,325.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,325.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,566.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,607.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,647.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,647.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,325.74,869.4,
PLATE 8 HOLE OFFSET,890080,CDM,278,RC,C1713,HCPCS,both,,,809.6,607.2,,647.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,325.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.28,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,325.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,566.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,607.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,647.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,647.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,325.78,869.4,
REPAIR WOUND TRUNK 2.6 CM TO 7.5 CM,6200511,CDM,360,RC,13101,HCPCS,outpatient,,,817,612.75,,653.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,328.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,408.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,408.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,408.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,328.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,328.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,653.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,612.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,653.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,653.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,328.76,858.6,
NM LUNG COMPLETE VQ,4400069,CDM,341,RC,78598,HCPCS,outpatient,,,818,613.5,,654.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,329.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,574.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,574.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,449.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,329.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,329.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,654.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,613.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,329.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,745.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,699.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,654.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,329.16,783.04,
SUTURE ANCHOR SWVLK TENOD BIOCOM,890260,CDM,278,RC,C1713,HCPCS,both,,,820,615,,656,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,329.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,451,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,656,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,329.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,329.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,574,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,656,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,656,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,329.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,329.97,869.4,
CONIZATION OF CERVIX,6100133,CDM,969,RC,57520,HCPCS,outpatient,,,820,615,,,,,,other,Not separately reimbursable for physician setting,196.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,288.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,492,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,288.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,288.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,288.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,196.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,196.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,288.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,288.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,196.74,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,461.02,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,288.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,403.4,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,196.74,492,
REMOVAL OF SWEAT GLAND LESION,6200363,CDM,510,RC,11450,HCPCS,outpatient,,,822,616.5,,657.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,452.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,657.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,330.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,330.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,657.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,616.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,657.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,330.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,657.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,330.77,3817.9,
DESTRUCTION OF TONGUE LESION,6200087,CDM,360,RC,41112,HCPCS,outpatient,,,826,619.5,,660.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,454.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,332.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,619.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4204.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,332.38,4204.78,
EXC FACE LESION SCALP < 2CM,6200545,CDM,360,RC,21011,HCPCS,outpatient,,,836,627,,668.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,336.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,336.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,627,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,336.41,2216.25,
NM GASTRIC EMPTY STUDY,4400012,CDM,341,RC,78264TC,HCPCS,outpatient,,,837,627.75,,669.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,336.81,669.6,
NM PAROTID/SALIVARY,4400025,CDM,341,RC,78230TC,HCPCS,outpatient,,,837,627.75,,669.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,336.81,669.6,
NM TAGGED RED CELL,4400058,CDM,341,RC,78278TC,HCPCS,outpatient,,,837,627.75,,669.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,418.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,336.81,669.6,
INJ ANEST AGNT; OTHER PERIPHERAL NERVE,7200066,CDM,360,RC,64450,HCPCS,outpatient,,,838,628.5,,670.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,337.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,460.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,337.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,337.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,628.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,952.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,337.21,952.29,
NM CEREBRAL FLOW,4400010,CDM,341,RC,78610TC,HCPCS,outpatient,,,840,630,,672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,338.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,420,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,420,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,420,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,462,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,338.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,338.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,338.02,672,
NM BRAIN-STATIC,4400009,CDM,341,RC,78605TC,HCPCS,outpatient,,,841,630.75,,672.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,338.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,420.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,420.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,420.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,462.55,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,338.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,672.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,672.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,338.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,672.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,338.42,672.8,
REMOVAL OF LYMPH NODE,6200248,CDM,360,RC,38500,HCPCS,outpatient,,,845,633.75,,676,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,464.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,340.03,5080.87,
SMALL BOWEL ENDOSCOPY,6200417,CDM,360,RC,44372,HCPCS,outpatient,,,845,633.75,,676,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,464.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,633.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,340.03,2573.96,
EXCISION OF NAIL WITH AMP DISTALPHALANX,6200154,CDM,360,RC,11752,HCPCS,outpatient,,,846,634.5,,676.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,340.43,676.8,
BICILLIN LA 2.4,3200085,CDM,636,RC,J0561,HCPCS,both,,,846.75,635.06,,677.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,423.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,423.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,465.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,340.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,677.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,635.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,677.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,30.24,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,677.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.16,846.75,
REMDESIVIR 100MG/NSS 250 ML IVPB,3205962,CDM,636,RC,J0248,HCPCS,both,,,850,637.5,,680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,467.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.06,850,
"PROCRIT 40,000 UNITS/ML",3207355,CDM,636,RC,J0885,HCPCS,both,,,850,637.5,,680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,467.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.34,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.09,850,
INFUSAPORT,6200191,CDM,360,RC,36533,HCPCS,outpatient,,,850,637.5,,680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,467.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.04,680,
EXC LESION ABD PERITONEUM AND OMENTUM,6200455,CDM,360,RC,49329,HCPCS,outpatient,,,850,637.5,,680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,467.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.04,7703.27,
REPAIR INTERMED FACE/NOS  2.5CM OR LESS,6200612,CDM,360,RC,12051,HCPCS,outpatient,,,850,637.5,,680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,467.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,718.61,
EXPLORE WOUND ABDOMEN/FLANK/BACK,6200168,CDM,360,RC,20102,HCPCS,outpatient,,,851,638.25,,680.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,680.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,680.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.44,3449.93,
COLONOSCOPY W/BIOPSY,6200329,CDM,510,RC,45380,HCPCS,outpatient,,,852,639,,681.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.84,1622.75,
COLONOSCOPY W/SUBMUCOUS INJECTION,6200594,CDM,510,RC,45381,HCPCS,outpatient,,,852,639,,681.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,639,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,342.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.84,1622.75,
ER LEVEL 4,1400147,CDM,450,RC,99284,HCPCS,outpatient,,,854,640.5,,683.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,352.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,469.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,329.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,329.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,352.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.98,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,352.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,528.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,329.13,854,
ER LEVEL 4 - MODIFIER,1400148,CDM,450,RC,9928425,HCPCS,outpatient,,,854,640.5,,683.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,427,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,427,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,427,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,469.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,343.65,683.2,
NM BONE 3 PHASE,4400004,CDM,341,RC,78315TC,HCPCS,outpatient,,,856,642,,684.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.8,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,344.45,684.8,
NM BONE LIMITED AREA,4400005,CDM,341,RC,78300TC,HCPCS,outpatient,,,856,642,,684.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.8,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,344.45,684.8,
NM BONE SPECT,4400006,CDM,341,RC,78320TC,HCPCS,outpatient,,,856,642,,684.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.8,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,344.45,684.8,
NM BONE WHOLE BODY,4400007,CDM,341,RC,78306TC,HCPCS,outpatient,,,856,642,,684.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.8,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,344.45,684.8,
GASTOSTOMY TUBE PLACEMENT PERCUT,6200526,CDM,360,RC,49440,HCPCS,outpatient,,,863,647.25,,690.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,347.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,474.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,347.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,347.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,690.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,647.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,690.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,690.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,347.27,2573.96,
LAC INTERM:N/H/F/EG 12.6-20.0 CM,1400124,CDM,450,RC,12045,HCPCS,outpatient,,,864,648,,691.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,432,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,432,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,432,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,475.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,347.67,858.6,
LAC INTERM:N/H/F/EG 20.1-30.0 CM,1400129,CDM,450,RC,12046,HCPCS,outpatient,,,864,648,,691.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,432,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,432,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,432,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,475.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,648,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,691.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,347.67,858.6,
ER LEVEL 5,1400149,CDM,450,RC,99285,HCPCS,outpatient,,,867,650.25,,693.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,576.56,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,476.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,759.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,348.88,867,
ER LEVEL 5 - MODIFIER,1400150,CDM,450,RC,9928525,HCPCS,outpatient,,,867,650.25,,693.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,433.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,433.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,433.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,348.88,693.6,
NMO ANTIBODIES IGG,2801420,CDM,302,RC,83520,HCPCS,outpatient,,,867,650.25,,693.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,45.72,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8.63,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,476.85,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,22.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,650.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,27.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,693.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.63,693.6,
COMPLEX REPAIR S/A/L 2.6-7.5CM,6200474,CDM,360,RC,13121,HCPCS,outpatient,,,868,651,,694.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,477.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,349.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,694.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,651,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,694.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,349.28,1365.74,
NM MECKELS LOCALIZATION,4400021,CDM,341,RC,78290TC,HCPCS,outpatient,,,869,651.75,,695.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,434.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,434.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,434.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,349.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,651.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,349.69,695.2,
COLPOSCOPY,400023,CDM,360,RC,57455,HCPCS,outpatient,,,873,654.75,,698.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,451.36,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,251.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,351.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,698.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,654.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,698.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,351.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,269.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,698.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,251.8,698.4,
CT LOWER EXTREMITY LT,4300063,CDM,352,RC,73706TCLT,HCPCS,outpatient,,,875,656.25,,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,352.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,352.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,352.1,700,
MIRENA SYSTEM,6100006,CDM,636,RC,J7302,HCPCS,both,,,879,659.25,,703.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,439.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,439.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,439.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,483.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,353.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,659.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,353.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,353.71,879,
XR FISTULAGRAM,4000055,CDM,320,RC,76080TC,HCPCS,outpatient,,,884,663,,707.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,486.2,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,355.72,707.2,
XR TRANSCATHETER RAD,4000139,CDM,320,RC,75898TC,HCPCS,outpatient,,,884,663,,707.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,486.2,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,707.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,355.72,707.2,
CLTX METACARP FX W/MANIP EA BONE PROFEE,7000044,CDM,982,RC,26605,HCPCS,outpatient,,,884,663,,,,,,other,Not separately reimbursable for physician setting,182.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,290.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,530.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,290.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,290.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,290.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,182.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,182.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,290.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,290.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,182.24,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,464.34,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,290.21,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,406.29,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,182.24,530.4,
NM BILLIARY SCAN W/O CCK,4400002,CDM,341,RC,78226,HCPCS,outpatient,,,888,666,,710.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,640.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,640.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,640.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,488.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,335.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,666,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.39,100,,,fee schedule,100% UHC fee schedule for outpatient setting,357.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,359.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,538.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,710.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,335.23,710.4,
CT GUID NEEDLE PLCMNT(BX ASP INJ) SURG,4300019,CDM,360,RC,77012TC,HCPCS,outpatient,,,890,667.5,,712,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,445,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,445,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,445,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,358.14,712,
CT GUIDED NEEDLE PLACEMENT,4300020,CDM,352,RC,77012TC,HCPCS,outpatient,,,890,667.5,,712,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,445,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,445,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,445,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,358.14,712,
CT GUIDED NEEDLE BIOPSY,6200468,CDM,360,RC,77012,HCPCS,outpatient,,,890,667.5,,712,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,447,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,447,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,447,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,358.14,712,
PR LIVER BX RADIOLOGY,4010217,CDM,972,RC,47000,HCPCS,outpatient,,,896,672,,,,,,other,Not separately reimbursable for physician setting,199.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,537.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,199.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,199.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,199.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,136.58,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,119.5,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,537.6,
LESION REMOVAL POLYPECTOMY,6200358,CDM,510,RC,45384,HCPCS,outpatient,,,896,672,,716.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,492.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,360.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,360.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,672,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,360.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,716.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,360.55,1622.75,
GASTRIC FEEDING TUBE REPOSITION IN OR,400078,CDM,490,RC,43761,HCPCS,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1311.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1311.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1311.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.32,1311.63,
ANCHOR ICONIX 2.3MM (3910-500-422),890075,CDM,278,RC,C1713,HCPCS,both,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,900,
LEADS UMRI US,5890005,CDM,275,RC,C1898,HCPCS,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,720,
COLONOSCOPY W/LESION REMOVAL,6200330,CDM,510,RC,45385,HCPCS,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,1622.75,
LAPAROSCOPY LIVER BIOPSY NOS,6200470,CDM,360,RC,47379,HCPCS,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,7703.27,
ANORECTAL WALL BIOPSY ANAL APPROACH,6200628,CDM,360,RC,45100,HCPCS,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,3797.53,
TRACHEOTOMY PLANNED,6200636,CDM,510,RC,31600,HCPCS,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4204.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,4419.87,
EXC BENIGN LESION OVER 4.OCM,6200112,CDM,360,RC,11426,HCPCS,outpatient,,,901,675.75,,720.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,495.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,362.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,720.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,720.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.56,3817.9,
PERICARDIOCENTESIS,1400154,CDM,450,RC,33016,HCPCS,outpatient,,,903,677.25,,722.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2202.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2202.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2202.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,496.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,363.37,2202.03,
PERITONOCENTESIS:PERITONEAL LAVAGE,1400244,CDM,450,RC,49080,HCPCS,outpatient,,,903,677.25,,722.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,451.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,451.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,451.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,677.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,363.37,722.4,
EXCISION DERMAL CYST NOSE SIMPLESUBQ,6200142,CDM,360,RC,30124,HCPCS,outpatient,,,905,678.75,,724,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,364.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,497.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,364.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,364.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,678.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,364.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,724,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,364.17,2051.58,
MM MAMMOGRAM NEEDLE LOCALIZATION,4000084,CDM,320,RC,19281,HCPCS,outpatient,,,907,680.25,,725.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,364.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.85,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,364.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,364.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,680.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,364.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2077.73,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,313.02,2216.25,
PR MM MAMMOGRAM NEEDLE LOCALIZATION,4010084,CDM,972,RC,19281,HCPCS,outpatient,,,907,680.25,,,,,,other,Not separately reimbursable for physician setting,161.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,544.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,161.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,161.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,96.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,161.97,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,154.27,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,96.42,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,134.99,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,96.42,544.2,
Incsn and drainage of vaginal hematoma,6900256,CDM,982,RC,57023,HCPCS,outpatient,,,908,681,,,,,,other,Not separately reimbursable for physician setting,203.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,314.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,544.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,314.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,314.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,314.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,203.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,203.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,314.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,314.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,203.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,503.62,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,314.76,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,440.66,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,203.1,544.8,
REMOVAL SWEAT GLAND LESION,6200408,CDM,360,RC,11470,HCPCS,outpatient,,,911,683.25,,728.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,366.59,3817.9,
"INJ ANEST AGNT FEMORAL NERVE, SINGLE",7200072,CDM,360,RC,64447,HCPCS,outpatient,,,911,683.25,,728.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,683.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,366.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,952.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,366.59,952.29,
REMOVAL ABDOMINAL LYMPH NODES,6200243,CDM,360,RC,38747,HCPCS,outpatient,,,912,684,,729.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,366.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,456,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,456,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,456,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,912,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,912,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,912,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,912,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,366.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,366.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,912,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,912,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,684,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,366.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,912,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,912,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,912,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,366.99,912,
HERNIA REPAIR WITH MESH,6200386,CDM,360,RC,49568,HCPCS,outpatient,,,913,684.75,,730.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,367.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,730.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,367.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,730.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,730.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,730.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,367.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,730.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,367.39,5430.82,
ANCHOR REELX STT 4.5MM,890230,CDM,278,RC,C1713,HCPCS,both,,,914.72,686.04,,731.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,368.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,368.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,731.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,731.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,368.08,914.72,
NM LUNG VENTILATION MULTIPLE PROJECT,4400020,CDM,341,RC,78598,HCPCS,outpatient,,,919,689.25,,735.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,369.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,574.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,574.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,505.45,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,735.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,369.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,369.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,735.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,689.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,735.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,369.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,745.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,699.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,735.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,369.81,783.04,
CSCOPE FLX ABLATION TUMOR POLYP OTHER LE,6200605,CDM,360,RC,45388,HCPCS,outpatient,,,920,690,,736,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,370.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,506,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,370.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,370.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,690,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,370.21,1622.75,
NM SENTINEL NODE INJECTION/IMAGING,4400054,CDM,341,RC,78195TC,HCPCS,outpatient,,,923,692.25,,738.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,371.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,461.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,461.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,461.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,371.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,371.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,738.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,692.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,738.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,371.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,738.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,371.42,738.4,
ER TEMP TRANSCUTANEOUS PACING,1400207,CDM,450,RC,92953,HCPCS,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,869.23,
RESPIRATORY PANEL,2801000,CDM,306,RC,87633,HCPCS,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1222.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1222.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1222.02,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,208.39,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,666.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,625.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,208.39,1222.02,
SFMC MENINGITIS/ENCEPHALITIS PANEL <REP>,2801335,CDM,301,RC,87483,HCPCS,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,804.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,804.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,804.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,208.39,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,48.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,48.14,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,666.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,625.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.14,804.87,
SFMC GI PANEL,2801374,CDM,306,RC,87507,HCPCS,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1209.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1209.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1209.79,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,208.39,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,509.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,541.81,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,416.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% UHC fee schedule for outpatient setting,416.78,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,666.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,625.16,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,208.39,1209.79,
XR FISTULAGRAM,4000189,CDM,320,RC,76080TC,HCPCS,outpatient,,,926,694.5,,740.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,372.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,372.62,740.8,
NM LIVER SPECT,4400013,CDM,341,RC,78205TC,HCPCS,outpatient,,,928,696,,742.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,464,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,510.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,373.43,742.4,
NM LIVER/SPLEEN,4400015,CDM,341,RC,78215TC,HCPCS,outpatient,,,928,696,,742.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,464,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,510.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,696,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,373.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,373.43,742.4,
GASTROSCOPY/BIOPSY,400083,CDM,490,RC,43239,HCPCS,outpatient,,,929,696.75,,743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1529.37,
INFUSION OF BAMLANIVIMAB,1899000,CDM,771,RC,M0239,HCPCS,outpatient,,,929,696.75,,743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,310.76,100,,,case rate,100% BCBS case rate,310.76,100,,,case rate,100% BCBS case rate,310.76,100,,,case rate,100% BCBS case rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,510.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,310.76,743.2,
INFUSION OF REGENERON,1899001,CDM,771,RC,M0243,HCPCS,outpatient,,,929,696.75,,743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,310.75,100,,,case rate,100% BCBS case rate,310.75,100,,,case rate,100% BCBS case rate,310.75,100,,,case rate,100% BCBS case rate,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,696.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,373.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,665.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,624.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,310.75,743.2,
LAG SCREW 10.5 X 85,890049,CDM,278,RC,C1713,HCPCS,both,,,930,697.5,,744,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,651,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,374.23,930,
LAG SCREW  10.5 X 90,890054,CDM,278,RC,C1713,HCPCS,both,,,930,697.5,,744,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,651,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,697.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,374.23,930,
"INJ ANEST AGNT;SCIATIC NERVE, SINGLE",7200070,CDM,360,RC,64445,HCPCS,outpatient,,,931,698.25,,744.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,374.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,512.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,374.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,374.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,744.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,698.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,952.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,744.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,374.63,952.29,
EXCISION OF LESION,6200152,CDM,360,RC,11644,HCPCS,outpatient,,,932,699,,745.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,375.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,512.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,745.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,375.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,745.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,699,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,745.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,745.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,745.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,375.04,2843.72,
EXCISION OF CYST,6200150,CDM,360,RC,42810,HCPCS,outpatient,,,935,701.25,,748,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,701.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4204.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,376.24,4419.87,
LACERATION INTERMEDIATE FACE 12.6-20.0CM,1400122,CDM,450,RC,12055,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION INTERMEDIATE FACE 20.1-30.0CM,1400130,CDM,450,RC,12056,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION INTERMEDIATE FACE 7.6-12.5 CM,1400134,CDM,450,RC,12054,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION INTERMEDIATE FACE OVER 30.0CM,1400137,CDM,450,RC,12057,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION SIMPLE:SCALP/NECK12.6-20.0CM,1400179,CDM,450,RC,12005,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION SIMPLE:SCALP/NECK20.1-30CM,1400181,CDM,450,RC,12006,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION SIMPLE: FACE/EAR 12.6-20.0 CM,1400183,CDM,450,RC,12016,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION SIMPLE: FACE/EARS 2.6-5.0 CM,1400184,CDM,450,RC,12013,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,748.8,
LACERATION SIMPLE:FACE/EARS 20.1-30.0 CM,1400185,CDM,450,RC,12017,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.91,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,748.8,
LACERATION SIMPLE: FACE/EARS 5.1-7.5 CM,1400186,CDM,450,RC,12014,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,748.8,
LACERATION SIMPLE:FACE/EARS 7.6-12.5 CM,1400187,CDM,450,RC,12015,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,748.8,
ER SIMPLE REPAIR FACE OVER 30.0 CM,1400188,CDM,450,RC,12018,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,748.8,
LACERATION SIMPLE:FACE/EARS UP TO 2.5CM,1400189,CDM,450,RC,12011,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,748.8,
ER SIMPLE REPAIR OVER 30.0 CM,1400190,CDM,450,RC,12007,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,748.8,
REP COMP 1.1 CM -2.5 CM SCALP ARM LEGS,1400279,CDM,450,RC,13120,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,376.65,858.6,
REMOVAL OF MESH ABDOMINAL WALL FOR INFEC,6200249,CDM,360,RC,11008,HCPCS,outpatient,,,936,702,,748.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,936,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,936,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,936,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,936,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,936,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,936,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,936,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,376.65,1365.74,
ER CLO TX NASAL FX W/O MANIP,1400035,CDM,450,RC,21310,HCPCS,outpatient,,,937,702.75,,749.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,515.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,377.05,749.6,
REPAIR LACERATION TONGUE,1400173,CDM,450,RC,41250,HCPCS,outpatient,,,937,702.75,,749.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,515.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,325.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,558.02,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,348.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.15,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,749.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,325.64,749.6,
LARGE BURN DRSG/DEBRIDEMENT:WO ANESTHESI,1400067,CDM,450,RC,16030,HCPCS,outpatient,,,938,703.5,,750.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,515.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,750.4,
MEDIUM BURN DRSG/DEBRIDEMENT:WO ANESTHES,1400068,CDM,450,RC,16025,HCPCS,outpatient,,,938,703.5,,750.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,515.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,155.74,750.4,
LACERATION INTERMEDIATE:FACE 12.6-20.0CM,1400123,CDM,450,RC,12035,HCPCS,outpatient,,,938,703.5,,750.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,515.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,750.4,
LACERATION INTERMEDIATE:FACE 20.1-30.0CM,1400128,CDM,450,RC,12036,HCPCS,outpatient,,,938,703.5,,750.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,515.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,377.45,858.6,
REP COMP 1.1 CM TO 2.5 CM-FACE MOUTH NEC,1400281,CDM,450,RC,13131,HCPCS,outpatient,,,938,703.5,,750.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,515.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,750.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,750.4,
GASTROSTROMY TUBE REPLACEMENT,1400177,CDM,450,RC,43760,HCPCS,outpatient,,,943,707.25,,754.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,379.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,471.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,707.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,379.46,754.4,
NIRXCELL 4.0 X 33,5890033,CDM,278,RC,C1876,HCPCS,both,,,950,712.5,,760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,522.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,382.28,950,
NIRXCELL 2.75 X 20,5890034,CDM,278,RC,C1876,HCPCS,both,,,950,712.5,,760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,522.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,382.28,950,
PLACE GASTROSTOMY TUBE,6200361,CDM,510,RC,43246,HCPCS,outpatient,,,950,712.5,,760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,522.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,382.28,2573.96,
NEUPOGEN 480 MCG INJ,3200599,CDM,636,RC,J1442,HCPCS,both,,,956.58,717.44,,765.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,384.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,478.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,478.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,478.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,526.12,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,384.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,384.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,765.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,717.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,765.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,765.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.99,956.58,
OMNIPAQUE 300 500ML,3206880,CDM,636,RC,Q9967,HCPCS,both,,,964,723,,771.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,387.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,482,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,482,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,530.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,771.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,387.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,723,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,771.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,771.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,387.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,387.91,964,
GASTRIC INTUB/ASP/THERAPEUTIC/LAVAGE,6200176,CDM,360,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
HIP DISLOCATION:WO ANESTHESIA,1400023,CDM,450,RC,27250,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
ELBOW DISLOCATION: WO ANESTHESIA,1400027,CDM,450,RC,24600,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
ER CLO TX RADIAL SHAFT FX WO MANIP,1400039,CDM,450,RC,25500,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
ER CLO TX RADIAL&ULNAR SHAFT FX WO MANIP,1400040,CDM,450,RC,25560,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
SHOULDER DISLOCATION:WO ANESTHESIA,1400059,CDM,450,RC,23650,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
ER REDUCTION OF CLOSED DISLOCATION,1400158,CDM,450,RC,27560,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
HIP DISLOCATION:WITH  ANESTHESIA,1400271,CDM,450,RC,27250,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
CLOSED TX DISTAL FIBULAR FX W MANIPULATI,1400274,CDM,450,RC,27788,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
ULNAR SHAFT DISLOCATION W MANIPULATION,1400276,CDM,450,RC,25535,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
FRACTURE-CLOSED DISTAL RADIAL WO MANIPUL,1400287,CDM,450,RC,25600,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
FRACTURE-ANKLE,1400288,CDM,450,RC,27810,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,388.72,2120.14,
FRACTURE-ANKLE DISTAL FIBIA,1400290,CDM,450,RC,27825,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,388.72,2120.14,
HCV REAL TIME,2800339,CDM,302,RC,87522,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,151.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,21.42,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,55.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,68.54,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.26,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.42,772.8,
CLTX METACARP FX W/MANIP EA BONE TECHNIC,7000043,CDM,761,RC,26605,HCPCS,outpatient,,,966,724.5,,772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,531.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,724.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,388.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.54,772.8,
"DRAIN OVARIAN CYST UNI/BILAT, VAG APPROA",6100699,CDM,969,RC,58800,HCPCS,outpatient,,,968,726,,,,,,other,Not separately reimbursable for physician setting,204.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,308.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,580.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,308.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,308.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,308.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,204.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,204.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,308.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,308.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,204.59,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,493.65,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,308.53,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,431.94,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,204.59,580.8,
EXC LESION OVER 4.0 CM,6200120,CDM,360,RC,11626,HCPCS,outpatient,,,971,728.25,,776.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,534.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,390.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,390.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,728.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,390.73,3817.9,
ER I&D PERIANAL CYST SUPERFICIAL,1400097,CDM,450,RC,46050,HCPCS,outpatient,,,984,738,,787.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,541.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,395.96,1228.22,
ER INCISION THROMB HEM EXT,1400104,CDM,450,RC,46083,HCPCS,outpatient,,,984,738,,787.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,541.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,738,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,395.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,787.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.32,787.2,
MASTOTOMY WITH EXPL OR DRAINAGE ABSCESS,6200209,CDM,360,RC,19020,HCPCS,outpatient,,,988,741,,790.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,543.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,397.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,397.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,741,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,397.57,3089.62,
INCISION & DRAINAGE OF RECTAL ABSCESS,6200188,CDM,360,RC,46040,HCPCS,outpatient,,,992,744,,793.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,399.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,545.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,399.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,399.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,744,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,399.18,3429.47,
S&I INJ CATH/VENT,5800174,CDM,480,RC,93555,HCPCS,outpatient,,,993,744.75,,794.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,496.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,496.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,496.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,399.58,794.4,
STENT PLACED VASC,5800183,CDM,320,RC,75960,HCPCS,outpatient,,,993,744.75,,794.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,496.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,496.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,496.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.15,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,399.58,794.4,
CATH INJ ROOT AORTOGRAPHY,5800050,CDM,480,RC,93567,HCPCS,outpatient,,,995,746.25,,796,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,796,
INJ LT VENT/ATRIAL ART,5800080,CDM,480,RC,93565,HCPCS,outpatient,,,995,746.25,,796,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,796,
INJ PULMONARY ARTERY,5800081,CDM,480,RC,93568,HCPCS,outpatient,,,995,746.25,,796,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,796,
INJ RT VENT/ATRIAL ARTERY,5800082,CDM,480,RC,93566,HCPCS,outpatient,,,995,746.25,,796,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,796,
EXC TUMOR SOFT TISS OR THORAX SUBCUTANEO,6200134,CDM,360,RC,21555,HCPCS,outpatient,,,996,747,,796.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,547.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,400.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,400.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,747,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,400.79,3710.83,
COLORECTAL SCREENING ON HIGH RISK PT,400021,CDM,490,RC,G0105,HCPCS,outpatient,,,998,748.5,,798.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,548.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1228.22,
COLORECTAL SCREENING ON NON-HIGH RISK PT,400022,CDM,490,RC,G0121,HCPCS,outpatient,,,998,748.5,,798.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1153.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,548.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,798.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1228.22,
XR VENOGRAM EXTREMITY UNILATERAL,4000133,CDM,320,RC,75820TC,HCPCS,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
MASTECTOMY SIMPLE,6200207,CDM,360,RC,,,outpatient,,,2225,1668.75,,1780,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,895.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,895.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,895.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1668.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,895.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,895.34,1780,
AORTAGRAM/ROOT,5800026,CDM,480,RC,93544,HCPCS,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
COLONOSCOPY W/BIOPSY (SINGLE OR MULTIPLE,6100503,CDM,521,RC,45380,HCPCS,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,1622.75,
EXCISION TUMOR LEG/ANKLE SUBQ <3M,6200159,CDM,360,RC,27618,HCPCS,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,2843.72,
INSERT TYBBEKED CV CATH,6200195,CDM,360,RC,36558,HCPCS,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,4402.75,
PR Bone Bx Superficial Radiology,4011157,CDM,972,RC,20220,HCPCS,outpatient,,,1003,752.25,,,,,,other,Not separately reimbursable for physician setting,106.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,601.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,106.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,106.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,136.58,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,85.36,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,119.5,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,85.36,601.8,
THOROCENTESIS W/TUBE INSERT,5800189,CDM,480,RC,32556,HCPCS,outpatient,,,1006,754.5,,804.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,404.81,2573.96,
DRAIN PENIS LESION,6200090,CDM,360,RC,54015,HCPCS,outpatient,,,1006,754.5,,804.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,754.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,404.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,804.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,404.81,3089.62,
NM TC 99M TILMANOCEPT,4400071,CDM,343,RC,A9500,HCPCS,outpatient,,,1012,759,,809.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,407.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,506,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,506,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,506,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,506,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,556.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,809.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,407.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,809.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,759,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,809.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,407.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,809.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,407.23,809.6,
NSF-INSUFFICIENT FUNDS,6200217,CDM,360,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
REMOVAL OF FOOT FOREIGN BODY COMPLICATED,6200245,CDM,360,RC,28193,HCPCS,outpatient,,,1018,763.5,,814.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,409.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,814.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,409.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,409.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,763.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,814.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,814.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,409.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,814.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,409.64,2216.25,
EXC THIGH/KNEE LESION SC <3CM,6200131,CDM,360,RC,27327,HCPCS,outpatient,,,1019,764.25,,815.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,410.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,410.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,410.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,815.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,764.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,815.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,410.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,815.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,410.05,3710.83,
NM MUGA BLOOD POOL IMAGING,4400022,CDM,341,RC,78472TC,HCPCS,outpatient,,,1020,765,,816,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,510,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,561,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,410.45,816,
REMOVAL OF INFUSAPORT,6200247,CDM,360,RC,36590,HCPCS,outpatient,,,1020,765,,816,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,561,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,765,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,410.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2061.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,816,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,410.45,2198.96,
EXCISION LESION 2.1-3.0CM,6100462,CDM,521,RC,11423,HCPCS,outpatient,,,1023,767.25,,818.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,562.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,767.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,411.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,818.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,411.66,2843.72,
EXCIS BENIGN LESION-FACE 1.1-2.0,400038,CDM,360,RC,11442,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,1316.03,
EXCIS BENIGN LESION-FACE 2.1-3.0,400039,CDM,360,RC,11443,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,2216.25,
EXCIS BENIGN LESION-FACE 3.1-4.0,400040,CDM,360,RC,11444,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,2216.25,
EXCIS BENIGN LESION-HEAD FT GEN <0.5,400041,CDM,360,RC,11420,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,2216.25,
EXCIS BENIGN LESION-HEAD FT GEN 0.6-1.0,400043,CDM,360,RC,11421,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,1316.03,
EXCIS BENIGN LESION-HEAD FT GEN 1.1-2.0,400044,CDM,360,RC,11422,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,2216.25,
EXCIS BENIGN LESION-TRUNK EXTEM 2.1-3.0,400051,CDM,360,RC,11403,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,1316.03,
EXCIS MAL LESION-FACE 2.1-3.0,400060,CDM,360,RC,11643,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,2216.25,
EXCIS MAL LESION-HEAD FEET GEN <0.5,400062,CDM,360,RC,11620,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,2216.25,
EXCIS MAL LESION-HEAD FEET GEN 1.1-2.0,400065,CDM,360,RC,11622,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,1316.03,
EXCIS MAL LESION-TRUNK EXTEM <0.5,400068,CDM,360,RC,11600,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,959.13,
EXCIS MAL LESION-TRUNK EXTEM 2.1-3.0,400072,CDM,360,RC,11603,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,1316.03,
EXCIS MAL LESION-TRUNK EXTEM 3.1-4.0,400073,CDM,360,RC,11604,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,1316.03,
ER BLOOD ADMINISTRATION,1400018,CDM,450,RC,36430,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,690.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,351.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,602.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,376.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,351.67,819.2,
GANGLION EXCISION,6200343,CDM,510,RC,25111,HCPCS,outpatient,,,1024,768,,819.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,768,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,412.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.06,2965.3,
ER DRAIN ABSCESS/CYST/HEMATOMA MOUTH,1400063,CDM,450,RC,40800,HCPCS,outpatient,,,1026,769.5,,820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,394.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,394.16,959.13,
REPAIR INTERMEDIATE WOUND 20.1CMTO 30CM,6200269,CDM,360,RC,12046,HCPCS,outpatient,,,1026,769.5,,820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,513,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,513,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,513,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,769.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,412.86,858.6,
ANCHOR ICONIX SPEED 2.3MM,890231,CDM,278,RC,C1713,HCPCS,both,,,1030,772.5,,824,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,566.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,721,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,414.47,869.4,
"EXCISION TUMOR, ABD WALL, <3 CM",6100684,CDM,969,RC,22902,HCPCS,outpatient,,,1030,772.5,,,,,,other,Not separately reimbursable for physician setting,281.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,325.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,618,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,325.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,325.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,325.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,281.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,281.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,325.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,325.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,281.9,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,520.91,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,325.57,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,455.8,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,281.9,618,
HEMORRHOIDECTOMY EXTERNAL 2 OR MORE GRPS,6200344,CDM,510,RC,46250,HCPCS,outpatient,,,1030,772.5,,824,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,566.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,414.47,4526.47,
CHOLANGIOPANCREATOGRAPHY ERCP W/STENTS,6200459,CDM,360,RC,43268,HCPCS,outpatient,,,1030,772.5,,824,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,515,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,566.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,772.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,414.47,824,
DESTRUCTION EXT EAR LESION NEC,6200086,CDM,360,RC,69110,HCPCS,outpatient,,,1031,773.25,,824.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,414.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,567.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,414.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,414.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,773.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,414.87,3817.9,
PICC Line Removal,6100568,CDM,521,RC,36589,HCPCS,outpatient,,,1032,774,,825.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,567.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,415.28,1560.65,
FNA W/O IMAGE,6200342,CDM,510,RC,10021,HCPCS,outpatient,,,1037,777.75,,829.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,417.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,932.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,570.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,417.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,417.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,829.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,777.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,417.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,829.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,932.28,
US ECHOCARDIOGRAM,4000171,CDM,483,RC,93306,HCPCS,outpatient,,,1039,779.25,,831.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1106.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1106.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1106.46,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,571.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,831.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,433.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,433.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,418.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,418.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,831.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,779.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,831.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,831.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,743.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,464.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,697.11,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,831.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,418.09,1106.46,
I & D DEEP ABSCESS OR HEMATOMA NECK THOR,6200516,CDM,360,RC,21501,HCPCS,outpatient,,,1045,783.75,,836,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,574.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,420.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,420.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,836,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,783.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,836,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,420.51,3817.9,
ER SPINAL PUNCTURE THERAPEUTIC,1400192,CDM,450,RC,62272,HCPCS,outpatient,,,1046,784.5,,836.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,575.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,952.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,420.91,952.29,
REMOVAL OF ANAL FISSURE,6200449,CDM,360,RC,46200,HCPCS,outpatient,,,1046,784.5,,836.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,575.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,420.91,4526.47,
INC & DRAIN BELOW FASCIA FOOT 1 BURSA SP,6200523,CDM,360,RC,28002,HCPCS,outpatient,,,1046,784.5,,836.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,575.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,784.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,420.91,3865.82,
XR KNEE ARTHROGRAM,4000076,CDM,322,RC,73580TC,HCPCS,outpatient,,,1048,786,,838.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,524,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,524,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,524,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,421.72,838.4,
VOLUME VENT SUBSEQ DAY,5200081,CDM,410,RC,94003,HCPCS,outpatient,,,1048,786,,838.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,576.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,786,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,838.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.06,838.4,
REPAIR ARTERIAL BLOCKAGE,6200262,CDM,360,RC,35474,HCPCS,outpatient,,,1050,787.5,,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,525,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,525,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,525,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,577.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,422.52,840,
REMOVE EPIDIDYMIS LESION,6200569,CDM,360,RC,54840,HCPCS,outpatient,,,1050,787.5,,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,577.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,787.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,422.52,4427.19,
EXCISION OF A LESION,6200147,CDM,360,RC,11606,HCPCS,outpatient,,,1051,788.25,,840.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,422.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,578.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,422.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,422.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,840.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,788.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,840.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,840.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,422.92,2843.72,
IV INFUSION BEBTELOVIMAB; & POST ADMIN M,1899012,CDM,771,RC,M0222,HCPCS,outpatient,,,1052,789,,841.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,423.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,526,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,526,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,526,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,323.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,578.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,841.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,302.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,302.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,423.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,423.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,323.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,841.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,323.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,789,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,841.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,423.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,518.01,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,323.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,485.63,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,841.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,302.29,841.6,
EXC SKIN/TIS FOR HIDRADENITIS COMPL REPR,6200128,CDM,360,RC,11451,HCPCS,outpatient,,,1057,792.75,,845.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,581.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,792.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,425.34,3817.9,
INJ MYELOGRAPHY AND/OR CT SPINAL901,4000011,CDM,360,RC,62284,HCPCS,outpatient,,,1060,795,,848,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,583,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,426.54,848,
EXCISION OF A LESION OVER 4.O CM,6200148,CDM,360,RC,11446,HCPCS,outpatient,,,1060,795,,848,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,583,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,795,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,426.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,426.54,3817.9,
NM LIVER VASCULAR FLOWW,4400014,CDM,341,RC,78140TC,HCPCS,outpatient,,,1062,796.5,,849.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,531,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,531,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,531,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,584.1,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,427.35,849.6,
NM RED CELL SEQUESTRATION,4400070,CDM,341,RC,78140TC,HCPCS,outpatient,,,1062,796.5,,849.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,531,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,531,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,531,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,584.1,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,427.35,849.6,
REMOVE TENDON SHEATH LESION,6200259,CDM,360,RC,26160,HCPCS,outpatient,,,1062,796.5,,849.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,584.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,796.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,427.35,2965.3,
LACERATION INTERMEDIATE FACE 2.6-5.0 CM,1400125,CDM,450,RC,12052,HCPCS,outpatient,,,1064,798,,851.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,585.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,851.2,
LAC INTERM: N/H/F/EG 2.6-7.5 CM,1400127,CDM,450,RC,12042,HCPCS,outpatient,,,1064,798,,851.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,585.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,851.2,
LAC INTERM:N/H/F/EG 7.6-12.5 CM,1400132,CDM,450,RC,12044,HCPCS,outpatient,,,1064,798,,851.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,532,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,532,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,532,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,585.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,428.15,858.6,
LACERATION INTERMEDIATE FACE UP TO 2.5CM,1400140,CDM,450,RC,12051,HCPCS,outpatient,,,1064,798,,851.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,585.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,851.2,
FBR:INCISION AND REMOVAL FB SIMPLE SUBCU,1400166,CDM,450,RC,10120,HCPCS,outpatient,,,1064,798,,851.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,718.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,585.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,798,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,851.2,
FHC-INC & DRAIN OF FOREIGN BODY SIMPLE,6900003,CDM,982,RC,10120,HCPCS,outpatient,,,1065,798.75,,,,,,other,Not separately reimbursable for physician setting,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,639,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,99.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,99.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,99.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,99.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,159.81,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,99.88,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,139.83,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,79.56,639,
REMOVAL OF TESTIS,6200254,CDM,360,RC,54520,HCPCS,outpatient,,,1068,801,,854.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,587.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4736.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,429.76,4736.99,
EXC SHOULDER LESION SC<3CM,6200528,CDM,360,RC,23075,HCPCS,outpatient,,,1068,801,,854.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,587.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,429.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,429.76,2843.72,
PLATE 8 HOLE VARIAX COMPRESSION BROAD,890118,CDM,278,RC,C1713,HCPCS,both,,,1068.1,801.08,,854.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,429.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,587.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,534.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,534.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,534.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,534.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,534.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,534.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,854.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,801.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,747.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,801.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,854.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,854.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,429.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,429.8,869.4,
EXC ARM/ELBOW LES SC<3CM,6200454,CDM,360,RC,24075,HCPCS,outpatient,,,1070,802.5,,856,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,588.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,430.57,2843.72,
REMOVAL SWEAT GLAND LESION,6200517,CDM,360,RC,11463,HCPCS,outpatient,,,1070,802.5,,856,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,588.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,802.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,430.57,3817.9,
CLOSED TX DISTAL  RADIUS W MANIPULATI,1400275,CDM,450,RC,25605,HCPCS,outpatient,,,1071,803.25,,856.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,589.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,803.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,856.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,430.97,2120.14,
GASTROSCOPY,400079,CDM,490,RC,43235,HCPCS,outpatient,,,1072,804,,857.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,589.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,349.65,1529.37,
GASTROSCOPY W ESOPHAGEAL DILATION,400082,CDM,490,RC,43248,HCPCS,outpatient,,,1072,804,,857.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1529.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,589.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1529.37,
REP COMPL EACH ADDL 5CM-LESS SCP ARM LEG,1400280,CDM,450,RC,13122,HCPCS,outpatient,,,1072,804,,857.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,431.37,857.6,
REP COMP EA ADL 5 CM OR L-FACE MOUTH NEC,1400283,CDM,450,RC,13133,HCPCS,outpatient,,,1072,804,,857.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,431.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,431.37,857.6,
CPR-RESPIRATORY,5200030,CDM,480,RC,92950,HCPCS,outpatient,,,1075,806.25,,860,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,432.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.07,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,591.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,241.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,432.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,432.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,806.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,432.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,413.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,258.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.04,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.54,860,
FHC-INC & DRAIN OF ABSCESS COMP MULTIPLE,6900002,CDM,982,RC,10061,HCPCS,outpatient,,,1077,807.75,,,,,,other,Not separately reimbursable for physician setting,113.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,175.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,646.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,175.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,175.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,175.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,113.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,113.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,175.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,175.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,113.8,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,280.62,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,175.39,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,245.55,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,113.8,646.2,
I&D COMPLEX/MULTIPLE ABSCESS,1400096,CDM,450,RC,10061,HCPCS,outpatient,,,1078,808.5,,862.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,727.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,592.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,862.4,
BB BLOOD-PLATELET PHERESIS(PTP),3000012,CDM,384,RC,P9034BL,HCPCS,outpatient,,,1078,808.5,,862.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,539,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,539,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,539,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,808.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,433.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,433.79,862.4,
LAPAROSCOPY ABDOMEN DIAGNOSTIC W/OR W/O,6200203,CDM,360,RC,49320,HCPCS,outpatient,,,1081,810.75,,864.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,594.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,434.99,7703.27,
REMOVAL OF FOREIGN BODY FOOT,6200246,CDM,360,RC,28192,HCPCS,outpatient,,,1081,810.75,,864.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,594.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,434.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,864.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,434.99,2843.72,
EXCISION TUMOR SOFT TIS ABD SUBCU<3CM,6200162,CDM,360,RC,22902,HCPCS,outpatient,,,1083,812.25,,866.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,435.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3757.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3757.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3757.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,595.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,866.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,435.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,866.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,812.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,866.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,866.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,435.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,866.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,435.8,3757.7,
PLATE 4 HOLE DISTAL FIB,890060,CDM,278,RC,C1713,HCPCS,both,,,1086,814.5,,868.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,437.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,597.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,814.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,814.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,814.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,814.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,437.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,814.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,437.01,869.4,
"LAP, SURGICAL, W BIOPSY SINGLE OR MULTIP",6100698,CDM,969,RC,49321,HCPCS,outpatient,,,1086,814.5,,,,,,other,Not separately reimbursable for physician setting,215.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,339.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,651.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,339.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,339.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,339.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,215.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,215.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,339.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,339.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,215.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,543.7,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,339.81,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,475.73,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,215.55,651.6,
PLATE 3 HOLE DISTAL FIB,890141,CDM,278,RC,C1713,HCPCS,both,,,1086.8,815.1,,869.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,437.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,597.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,543.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,869.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,815.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,437.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,815.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,869.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,869.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,869.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,437.33,869.44,
EXC TUMOR SOFT TIS PELVIS/THIGH SUB <3Cm,6200629,CDM,360,RC,27047,HCPCS,outpatient,,,1087,815.25,,869.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,437.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,597.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,869.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,437.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,437.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,869.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,815.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,869.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,869.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,869.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,437.41,3817.9,
PLATE OMEGA 140' 2 HOLE,890077,CDM,278,RC,C1713,HCPCS,both,,,1087.9,815.93,,870.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,437.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,543.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,543.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,870.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,815.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,815.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,437.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,761.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,815.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,870.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,870.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,437.77,870.32,
PLATE 2 HOLE 135 DEGREE OMEGA 3,890041,CDM,278,RC,C1713,HCPCS,both,,,1088,816,,870.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,761.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,437.81,870.4,
GASTROSTROMY TUBE REPLACEMENT,1400293,CDM,450,RC,43762,HCPCS,outpatient,,,1092,819,,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,737.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.32,873.6,
INJECTION SPINE  WITH CONTRAST,4200069,CDM,320,RC,62284,HCPCS,outpatient,,,1092,819,,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.71,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600.6,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,819,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,439.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,439.42,873.6,
PR INJECTION SPINE WITH CONTRAST,4210069,CDM,972,RC,62284,HCPCS,outpatient,,,1092,819,,,,,,other,Not separately reimbursable for physician setting,135.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,655.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,135.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,135.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,82.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,135.28,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,131.23,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,82.02,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,114.83,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.02,655.2,
PLACEMENT OF CATHETER IN ARTERY,6200232,CDM,360,RC,36247,HCPCS,outpatient,,,1095,821.25,,876,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,440.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1101.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,602.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,440.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,821.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,440.63,1101.24,
EXC LESION FACE 2CM OR GREATER,6200119,CDM,360,RC,21012,HCPCS,outpatient,,,1100,825,,880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,605,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,442.64,2216.25,
SMARTPORT SSDX-16-I,90001251,CDM,278,RC,C1788,HCPCS,both,,,1100,825,,880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,770,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,442.64,880,
EXCISION OF SPERMATIC VARICOCELE,6200436,CDM,360,RC,55040,HCPCS,outpatient,,,1105,828.75,,884,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,444.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,607.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,884,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,444.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,444.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,884,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,828.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,884,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,884,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,444.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,884,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,444.65,5430.82,
CARDIAC EVENT RECORDER REMOVAL,5800048,CDM,480,RC,33284,HCPCS,outpatient,,,1106,829.5,,884.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,445.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,553,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,553,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,553,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,608.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,884.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,445.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,884.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,829.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,884.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,884.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,445.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,884.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,445.05,884.8,
"INFUSION OF SOTROVIMAB, INCLUDES ADMIN M",1899006,CDM,771,RC,M0247,HCPCS,outpatient,,,1113,834.75,,890.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,447.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,556.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,556.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,556.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,612.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,447.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,447.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,834.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,447.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,665.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,624.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,388.54,890.4,
"INFUSION OF BAM/ETESEVIMAB, INCLUDES MON",1899005,CDM,771,RC,M0245,HCPCS,outpatient,,,1114,835.5,,891.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,448.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,557,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,612.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,891.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,388.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,448.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,448.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,891.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,835.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,891.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,448.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,665.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,416.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,624.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,891.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,388.54,891.2,
NM LOCALIZATION-LIMITED (BREAST),4400017,CDM,341,RC,78800TC,HCPCS,outpatient,,,1115,836.25,,892,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,448.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,557.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,613.25,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,448.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,892,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,836.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,892,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,448.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,892,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,448.68,892,
NM QUANTITATIVE DIFF FUNCTION,4400048,CDM,341,RC,78582,HCPCS,outpatient,,,1120,840,,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,450.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,592.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,592.96,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,616,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,896,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,450.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,450.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,896,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,840,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,896,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,450.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,745.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,699.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,896,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,435.12,896,
NM RENAL FLOW MULTIPLE STUDIES,4400049,CDM,341,RC,78709TC,HCPCS,outpatient,,,1125,843.75,,900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,452.7,900,
NM RENAL FLOW W/O PHARMACOLGIC INT,4400050,CDM,341,RC,78707TC,HCPCS,outpatient,,,1125,843.75,,900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,452.7,900,
NM RENAL FLOW W/PHARMACOLGIC INT,4400051,CDM,341,RC,78708TC,HCPCS,outpatient,,,1125,843.75,,900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,452.7,900,
NM RENAL VASCULAR FLOW,4400052,CDM,341,RC,78701TC,HCPCS,outpatient,,,1125,843.75,,900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,452.7,900,
NM RENAL-STATIC ONLY,4400053,CDM,341,RC,78700TC,HCPCS,outpatient,,,1125,843.75,,900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.75,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,843.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,452.7,900,
XR SHOULDER ARTHROGRAM,4000110,CDM,322,RC,73040TC,HCPCS,outpatient,,,1127,845.25,,901.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,453.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,563.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,563.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,619.85,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,901.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,453.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,901.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,845.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,901.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,901.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,453.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,901.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,453.5,901.6,
THYROID BIOPSY IN RADIOLOGY,4000199,CDM,360,RC,60100,HCPCS,outpatient,,,1130,847.5,,904,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,454.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,621.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,454.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,454.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,847.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,336.95,959.13,
"ERCP DIAGNOSTIC W/WO COLL,BRUSH,OR WASH",6200103,CDM,360,RC,43260,HCPCS,outpatient,,,1131,848.25,,904.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,455.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,622.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,455.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,455.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,848.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,455.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4819.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,455.11,4819.1,
PR XR MYELOGRAM LUMBAR,4010095,CDM,972,RC,62304,HCPCS,outpatient,,,1140,855,,,,,,other,Not separately reimbursable for physician setting,172.29,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,114.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,684,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,114.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,114.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,114.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,172.29,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,172.29,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,114.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,114.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,172.29,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,183.14,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,114.46,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,160.24,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,114.46,684,
EXC FOOT/TOE TUMOR >1CM,6200114,CDM,360,RC,28039,HCPCS,outpatient,,,1143,857.25,,914.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,628.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,459.94,5022.7,
EXP WOUND EXTREMITY,6200164,CDM,360,RC,20103,HCPCS,outpatient,,,1143,857.25,,914.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,628.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,857.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,459.94,2216.25,
SCREW LAG 10.5 X 95,890291,CDM,278,RC,C1713,HCPCS,both,,,1146.14,859.61,,916.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,461.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,573.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,916.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,859.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,859.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,859.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,859.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,461.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,802.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,916.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,916.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,461.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,461.21,916.91,
PR MYELOGRAM CERVICAL,4010094,CDM,972,RC,62302,HCPCS,outpatient,,,1155,866.25,,,,,,other,Not separately reimbursable for physician setting,174.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,693,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,174.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,174.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,174.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,185.78,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,162.55,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,693,
SFMC CPT 81229 CHG ONLY,2801379,CDM,311,RC,81229,HCPCS,outpatient,,,1160,870,,928,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2474.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2474.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2474.28,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,580,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,638,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,1508,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1508,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1508,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1508,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1508,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1508,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,928,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,870,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,143.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,143.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,928,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,870,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,928,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1160,100,,,fee schedule,100% UHC fee schedule for outpatient setting,143.24,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1856,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1740,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,928,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,143.24,2474.28,
HEMORRHOIDECTOMY INT & EXT SINGLEGRP,6200181,CDM,360,RC,46255,HCPCS,outpatient,,,1161,870.75,,928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,467.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,928.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,467.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,467.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,928.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,870.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,928.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,467.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,928.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,467.19,4526.47,
ER REMOVAL FB FOOT SUBCUTANEOUS,1400162,CDM,450,RC,28190,HCPCS,outpatient,,,1165,873.75,,932,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,640.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,468.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,873.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,932,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.8,959.13,
EXCISION OF NAIL PARTIAL OR COMP,6900009,CDM,982,RC,11750,HCPCS,outpatient,,,1165,873.75,,,,,,other,Not separately reimbursable for physician setting,128.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,699,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,96.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,128.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,128.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,96.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,128.49,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,154.37,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,96.48,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,135.07,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,96.48,699,
EXCISION: INGROWN TOENAIL,1400076,CDM,450,RC,11750,HCPCS,outpatient,,,1166,874.5,,932.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,469.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,641.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,469.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,469.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,874.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,469.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,321.76,932.8,
LAPAROSCOPY TUBAL CAUTERY,6200357,CDM,510,RC,58670,HCPCS,outpatient,,,1182,886.5,,945.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,475.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,650.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,475.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,945.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,886.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,475.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,945.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,475.64,8162.33,
SVC GRAM,5800185,CDM,320,RC,75827,HCPCS,outpatient,,,1190,892.5,,952,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,478.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,654.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,478.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,478.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,952,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2249.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,478.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2061.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,952,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,478.86,2249.82,
EXCISION TUMOR SOFT BACK OR FLANK<3CM,6200161,CDM,360,RC,21930,HCPCS,outpatient,,,1191,893.25,,952.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,479.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,655.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,479.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,479.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,893.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,479.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,479.26,3710.83,
REMOVAL FB DEEP UPPER ARM OR ELBOW AREA,6200487,CDM,360,RC,24201,HCPCS,outpatient,,,1194,895.5,,955.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,656.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,955.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,480.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,955.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,895.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,955.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,955.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,955.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,480.47,3817.9,
XR MYELOGRAM THORACIC,4000096,CDM,320,RC,62303,HCPCS,outpatient,,,1198,898.5,,958.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,658.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,958.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,958.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,898.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,958.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,958.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1094.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1026.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,958.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.08,1957.1,
PR XR MYELOGRAM THORACIC,4010096,CDM,972,RC,62303,HCPCS,outpatient,,,1198,898.5,,,,,,other,Not separately reimbursable for physician setting,180.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,718.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,180.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,180.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,180.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,185.78,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,116.11,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,162.55,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,116.11,718.8,
PATELLA TRIATHLON X3 SYMMETRIC,890266,CDM,278,RC,C1776,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,960,
VISTASEQ 8,2801108,CDM,301,RC,81321,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1279.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1279.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1279.8,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,300,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,780,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,780,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,780,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,780,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,780,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,780,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,600,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,100,,,fee schedule,100% UHC fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,960,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,600,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,300,1279.8,
SP VENOGRAM,5800177,CDM,320,RC,75820,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,649.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,649.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,649.97,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2249.82,100,,,fee schedule,100% UHC fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2061.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,2249.82,
INGEVITY MRI-IS-1 MODEL 7741/LEADS,5890003,CDM,275,RC,C1898,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
SYSTEM CORONARY STENT MINI VISION MULTI-,5890015,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
STENT MULTI-LINK VISION CORONARY,5890025,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
STENT MULTI-LINK MINI VISION CORONARY,5890026,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
STENT CORONARY MULTI-LINK RX ULTRA,5890045,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
STENT CORONARY MULTI-LINK RX ULTRA,5890046,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
STENT CORONARY MULTI-LINK VISION,5890047,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
STENT MULTI-LINK VISION CORONARY SYSTEM,5890082,CDM,278,RC,C1874,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,960,
STENT MULTI-VISION CORONARY SYSTEM,5890102,CDM,278,RC,C1874,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,960,
EXP LAPAROTOMY,6100096,CDM,521,RC,44180,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,8162.33,
ABDOMEN SURGERY PROCEDURE,6100105,CDM,521,RC,49999,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,4264.84,
LAP UNILAT SALPIN-OOPHOR,6100156,CDM,521,RC,58661,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,8162.33,
LAPAROSCOPY  EXCISE LESION,6100157,CDM,521,RC,58662,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,8162.33,
COLONOSCOPY W/LESION REMOVAL,6100542,CDM,521,RC,45385,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,1622.75,
COLONOSCOPY FLEXIBLE W/ ABLATION,6100579,CDM,521,RC,45385,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,1622.75,
"Excision, benign lesion >4.0cm",6100726,CDM,521,RC,11426,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,3817.9,
UMBIL HERNIA REPAIR UNDER 5YRS,6200308,CDM,360,RC,49580,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,5430.82,
INSERT TUNNELED CV CATH,6200352,CDM,510,RC,36561,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,5147.17,
TUBAL LIG ABD/VAG UNIL/BIL,6200609,CDM,360,RC,58600,HCPCS,outpatient,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,5080.81,
CORONARY STENT  3.5 1007849-15,90000436,CDM,278,RC,C1874,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,960,
LAB WORK,6200353,CDM,510,RC,,,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
CORONARY STENT SYSTEM 1007823-12,90000442,CDM,278,RC,C1874,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,960,
STENT CORONARY 1007847-15,90001557,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
STENT CORONARY  COBALT VI,90001558,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
CORONARY STENT SYSTEM 1007847-12,90006598,CDM,278,RC,C1876,HCPCS,both,,,1200,900,,960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,482.88,960,
OMENTAL FLAP INTRA ABDOMINAL,6200219,CDM,360,RC,49905,HCPCS,outpatient,,,1203,902.25,,962.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,601.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,601.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,601.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1203,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,661.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1203,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1203,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,484.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,484.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1203,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1203,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,902.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,484.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1203,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1203,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1203,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,484.09,1203,
NM BILIARY LIVER FUNCTION,4400001,CDM,341,RC,78227,HCPCS,outpatient,,,1214,910.5,,971.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,883.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,883.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,883.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,667.7,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,745.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,699.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,435.12,971.2,
NM BILLIARY SCAN WITH CCK,4400003,CDM,341,RC,78227,HCPCS,outpatient,,,1214,910.5,,971.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,883.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,883.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,883.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,667.7,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,435.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,910.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783.04,100,,,fee schedule,100% UHC fee schedule for outpatient setting,488.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,745.61,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,466.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,699.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,435.12,971.2,
EP EVAL ICD GENERATOR TESTING,5800065,CDM,480,RC,93641,HCPCS,outpatient,,,1220,915,,976,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,490.93,1467.06,
EP EVAL ICD IMPLANT LEADS,5800066,CDM,480,RC,93640,HCPCS,outpatient,,,1220,915,,976,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,490.93,1467.06,
EP EVAL ICD TOTAL PROG/REPROG,5800067,CDM,480,RC,93642,HCPCS,outpatient,,,1220,915,,976,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1467.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1031.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,671,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,963.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,963.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,963.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1031.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1650.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1031.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,490.93,1650.94,
PLATE 3 HOLE DISTAL FIBULA,890176,CDM,278,RC,C1713,HCPCS,both,,,1224.3,918.23,,979.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,492.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,673.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,612.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,979.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,492.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,918.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,979.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,979.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,492.66,979.44,
EXPLORE ABDOMINAL VESSELS,6100092,CDM,521,RC,35840,HCPCS,outpatient,,,1225,918.75,,980,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,612.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1225,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,673.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1225,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1225,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1225,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1225,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1225,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1225,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1225,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1225,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,492.94,1225,
LAPAROSCOPY ASPIRATION OF CAVITYOR CYST,6200204,CDM,360,RC,49322,HCPCS,outpatient,,,1225,918.75,,980,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,673.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,918.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,492.94,7703.27,
XR MYELOGRAM TOTAL,4000097,CDM,320,RC,62305,HCPCS,outpatient,,,1243,932.25,,994.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,683.65,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1094.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1026.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,500.18,1957.1,
PR XR MYELOGRAM TOTAL,4010097,CDM,972,RC,62305,HCPCS,outpatient,,,1243,932.25,,,,,,other,Not separately reimbursable for physician setting,187.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,745.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,119.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,119.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,119.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,187.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,187.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,119.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,119.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,187.67,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,190.45,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,119.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,166.64,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,119.03,745.8,
SURGICAL EXCISION OF HYDROCELE,6200478,CDM,360,RC,55060,HCPCS,outpatient,,,1243,932.25,,994.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,683.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4736.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,994.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,500.18,4736.99,
ER CRITICAL CARE EA HOUR AFTER,1400053,CDM,450,RC,99292,HCPCS,outpatient,,,1248,936,,998.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,842.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,842.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,842.52,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,502.2,998.4,
ER CRITICAL CARE EA HOUR W MOD/25,1400054,CDM,450,RC,9929225,HCPCS,outpatient,,,1248,936,,998.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,624,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,936,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,502.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,502.2,998.4,
DIURIL INJ 500MG,3200257,CDM,636,RC,J1205,HCPCS,both,,,1250,937.5,,1000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,687.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,503,1000,
ERCP W/SPINCTEROTOMY/PAPILLOTOMY,6200105,CDM,360,RC,43262,HCPCS,outpatient,,,1250,937.5,,1000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,687.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,937.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4819.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,503,4819.1,
NM TESTICULAR/FLOW,4400059,CDM,341,RC,78761TC,HCPCS,outpatient,,,1252,939,,1001.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,626,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,626,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,626,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.6,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1001.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,503.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,939,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1001.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1001.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,503.8,1001.6,
BIOPSY 3,6200375,CDM,360,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
STENT CORONARY 3.0 1007848-15,90001559,CDM,278,RC,C1874,HCPCS,both,,,1260,945,,1008,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,882,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,945,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,507.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1008,
BRONCHOSCOPY DIAG/THER,400008,CDM,361,RC,31624,HCPCS,outpatient,,,1266,949.5,,1012.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,696.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,509.44,2362.57,
BRONCHOSCOPY W/WASHING/SECRETION COLL,400009,CDM,490,RC,31622,HCPCS,outpatient,,,1266,949.5,,1012.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,696.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.65,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,349.65,2362.57,
BRONCHOSCOPY/BIOPSY,400010,CDM,361,RC,31625,HCPCS,outpatient,,,1266,949.5,,1012.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1782.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,696.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1378.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,949.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2362.57,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1476.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1012.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,509.44,2362.57,
ANAL FISTULOTOMY,6200055,CDM,360,RC,46270,HCPCS,outpatient,,,1275,956.25,,1020,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,701.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,513.06,4526.47,
ERCP W/REMOVAL CALCULUS FROM DUCTS,6200104,CDM,360,RC,43264,HCPCS,outpatient,,,1275,956.25,,1020,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3529.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,701.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2812.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,956.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,513.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4819.1,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3011.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,513.06,4819.1,
PR BX MUSCLE PERQ NEEDLE,4010213,CDM,972,RC,20206,HCPCS,outpatient,,,1277,957.75,,,,,,other,Not separately reimbursable for physician setting,152.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,55.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,766.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,55.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,55.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,55.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,152.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,152.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,55.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,55.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,152.6,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,88.37,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,55.23,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,77.32,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,55.23,766.2,
HYPERRAB 300U/1 ML SDV,3204816,CDM,636,RC,90375,HCPCS,both,,,1278.25,958.69,,1022.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,514.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,703.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,639.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1022.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,958.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,958.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,958.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,958.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,514.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1022.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,958.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1022.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,444.38,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.61,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1022.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,277.74,1022.6,
VISTASEQ 4,2801104,CDM,301,RC,81298,HCPCS,outpatient,,,1284,963,,1027.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,516.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,642,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,642,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,642,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320.92,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,706.2,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,834.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,834.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,834.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,834.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,834.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,834.41,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1027.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,963,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,963,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,963,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,963,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,641.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,641.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,641.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,516.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,641.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1027.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,641.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,963,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1027.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,641.85,100,,,fee schedule,100% UHC fee schedule for outpatient setting,516.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1026.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,641.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,962.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1027.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,320.92,1027.2,
AMPUTATION OF TOE,6200053,CDM,360,RC,28820,HCPCS,outpatient,,,1296,972,,1036.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,521.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,712.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1036.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,521.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,521.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1036.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,972,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1036.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1036.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,521.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1036.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,521.51,4399.33,
EXCISION OF HYDROCELE OF SPERMATIC CORD,6200151,CDM,360,RC,55500,HCPCS,outpatient,,,1298,973.5,,1038.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,522.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,713.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,522.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,522.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1038.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,973.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1038.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1038.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,522.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4736.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1038.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,522.32,4736.99,
INSERT PICVAD CATH,6200194,CDM,360,RC,36571,HCPCS,outpatient,,,1300,975,,1040,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,715,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,523.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,523.12,4402.75,
EXC MALIG LESION FACIAL AREA OVER4CM,6200124,CDM,360,RC,11646,HCPCS,outpatient,,,1303,977.25,,1042.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,977.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,524.33,3817.9,
EXT ANT NECK SUBQ TISS FASC PERQ,6200565,CDM,360,RC,64788,HCPCS,outpatient,,,1306,979.5,,1044.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3283.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3283.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3283.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,718.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1550.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1550.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1550.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,525.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,525.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1044.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,979.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1044.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2656.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1044.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,525.53,3283.97,
ER EXCISION HEMORRHOID EXTERNAL,1400075,CDM,450,RC,46999,HCPCS,outpatient,,,1308,981,,1046.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,526.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,664.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,719.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1046.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,526.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,526.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1046.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,981,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1046.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1046.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,526.34,1228.22,
ENDOMETR ABLATION,6100151,CDM,521,RC,58353,HCPCS,outpatient,,,1323,992.25,,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,532.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,727.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1058.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,532.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,532.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1058.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,992.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1058.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,532.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1058.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,532.38,6850.42,
FLEX SIG CANCER SCREENING,400075,CDM,490,RC,G0104,HCPCS,outpatient,,,1328,996,,1062.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,554.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,554.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,554.45,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,730.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,716.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,534.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1062.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,996,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1062.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1062.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,767.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.46,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1062.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,534.39,1228.22,
EXC TUMOR SOFT TIS UPPER ARM/ELBOW 3CM>,6200133,CDM,360,RC,24071,HCPCS,outpatient,,,1333,999.75,,1066.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,536.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,733.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1066.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,536.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1066.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,999.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1066.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1066.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1066.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,536.4,5022.7,
ER REMOVAL FB EMBEDDED MOUTH SIMPLE,1400161,CDM,450,RC,40804,HCPCS,outpatient,,,1334,1000.5,,1067.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,536.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,116.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,733.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,536.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1067.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1000.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1067.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.8,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1067.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,116.34,1220.05,
THORACENTESIS W/TUBE INSERTION  INCLUDES,400147,CDM,361,RC,32422,HCPCS,outpatient,,,1341,1005.75,,1072.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,539.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,670.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,670.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,670.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,737.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,539.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,539.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1072.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1005.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1072.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,539.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1072.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,539.62,1072.8,
UNILATERAL REDUCTION MAMMOPLASTY,6200403,CDM,360,RC,19300,HCPCS,outpatient,,,1344,1008,,1075.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,739.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,540.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,540.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1075.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1008,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1075.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,540.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1075.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,540.83,5080.87,
REMOVAL OF ANAL FISTULA,6200393,CDM,360,RC,46275,HCPCS,outpatient,,,1347,1010.25,,1077.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,542.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,740.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,542.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,542.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1077.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1010.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1077.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,542.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1077.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,542.03,4526.47,
VISTASEQ GYN CANCER PANEL,2801100,CDM,301,RC,81292,HCPCS,outpatient,,,1350,1012.5,,1080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1440.63,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1440.63,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1440.63,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,337.7,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,742.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,878.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,878.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,878.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,878.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,878.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,878.02,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,675.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675.4,100,,,fee schedule,100% UHC fee schedule for outpatient setting,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1080.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,675.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1013.1,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,337.7,1440.63,
AREDIA 90MG (PAMIDRONATE) INJ,3200018,CDM,636,RC,J2430,HCPCS,both,,,1350,1012.5,,1080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,742.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,675,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1012.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,543.24,1080,
EXC ARM ELBOW TUMOR DEEP <5CM,6200573,CDM,360,RC,24076,HCPCS,outpatient,,,1354,1015.5,,1083.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,744.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,544.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1083.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1015.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1083.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,544.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1083.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,544.85,3817.9,
TRAUMA 1.25 VITOSS BB,890164,CDM,278,RC,C1713,HCPCS,both,,,1356,1017,,1084.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,545.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,745.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,678,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1017,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1017,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1017,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1017,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,545.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,545.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,949.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1017,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,545.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,545.65,1084.8,
EXCISION OF CYST,6200009,CDM,510,RC,19120,HCPCS,outpatient,,,1360,1020,,1088,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,547.26,5080.87,
SPINAL PUNCTURE; LUMBAR; DX; TECHNICAL,7000047,CDM,761,RC,62270,HCPCS,outpatient,,,1360,1020,,1088,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1020,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,547.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,952.29,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,595.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,892.77,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,429.76,1088,
ING HERNIA 6MO TO UNDER 5YRS;REDUCIBLE,6200350,CDM,510,RC,49500,HCPCS,outpatient,,,1361,1020.75,,1088.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,547.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,547.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,547.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1020.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,547.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,547.67,5430.82,
EXC LESION ANKLE 3CM OR GREATER,6200118,CDM,360,RC,27632,HCPCS,outpatient,,,1363,1022.25,,1090.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,548.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,749.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,548.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,548.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1022.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,548.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,548.47,5022.7,
INSERT TUNNELED CV CATH IN OR (TLC),400089,CDM,360,RC,36583,HCPCS,outpatient,,,1372,1029,,1097.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,754.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,552.09,7596.28,
REMOVAL OF INFUSAPORT,400128,CDM,361,RC,36590,HCPCS,outpatient,,,1372,1029,,1097.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,754.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1029,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2061.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1097.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,552.09,2198.96,
EXCISION VAGINAL CYST OR TUMOR,6100464,CDM,521,RC,57135,HCPCS,outpatient,,,1375,1031.25,,1100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,756.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,553.3,4178.79,
REPAIR EPIGASTRIC HERNIA REDUCIBLE,6200268,CDM,360,RC,49570,HCPCS,outpatient,,,1375,1031.25,,1100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,756.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1031.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,553.3,5430.82,
VOLUME VENT INITIAL DAY I/P OR OBS,5200080,CDM,410,RC,94002,HCPCS,outpatient,,,1376,1032,,1100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,342.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,756.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,480.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,514.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.37,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.06,1100.8,
EXC TUMOR THIGH OR KNEE AREA <3CM,6200135,CDM,360,RC,27337,HCPCS,outpatient,,,1376,1032,,1100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,756.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,553.7,5022.7,
NEUROPLASTY,6200359,CDM,510,RC,64721,HCPCS,outpatient,,,1376,1032,,1100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3283.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3283.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3283.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,756.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1550.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1550.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1550.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,553.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2656.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1660.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,553.7,3283.97,
EXCISION TUMOR SHOULDER 3CM OR >SUBCUT,6200160,CDM,360,RC,23071,HCPCS,outpatient,,,1380,1035,,1104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,555.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,759,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,555.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,555.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1035,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,555.31,5022.7,
INSERT PICC CATH,6200193,CDM,360,RC,36569,HCPCS,outpatient,,,1390,1042.5,,1112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,764.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,559.34,2198.94,
INSERT PICC WO SUBCU PORT >AGE 5,6200438,CDM,360,RC,36569,HCPCS,outpatient,,,1390,1042.5,,1112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,764.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,559.34,2198.94,
NIPPLE EXP W/WO EXC DUCT,6200635,CDM,510,RC,19110,HCPCS,outpatient,,,1390,1042.5,,1112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,764.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1042.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,559.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,559.34,5080.87,
DRAINAGE OF TENDON SHEATH DIGIT/PALM,6200097,CDM,360,RC,26020,HCPCS,outpatient,,,1392,1044,,1113.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,560.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,765.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,560.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,560.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1044,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,560.14,4399.33,
BIOPSY OF A LYMP NODE,6200005,CDM,982,RC,38510,HCPCS,outpatient,,,1399,1049.25,,,,,,other,Not separately reimbursable for physician setting,314.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,412.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,839.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,412.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,412.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,412.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,314.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,314.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,412.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,412.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,314.15,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,659.5,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,412.19,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,577.07,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,314.15,839.4,
VAGINAL DELIVERY ONLY,6100490,CDM,521,RC,59409,HCPCS,outpatient,,,1400,1050,,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,770,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.36,4178.79,
EXCISE SUBMAXILLARY GLAND,6200136,CDM,360,RC,42440,HCPCS,outpatient,,,1400,1050,,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,770,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7891.73,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.36,7891.73,
DRAINAGE OF PELVIC ABSCESS,6200094,CDM,360,RC,57010,HCPCS,outpatient,,,1401,1050.75,,1120.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,563.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,770.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,563.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,563.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1050.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,563.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,563.76,4178.79,
EXC FOREARM LESION SC 3 CM/,6200564,CDM,360,RC,25071,HCPCS,outpatient,,,1402,1051.5,,1121.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,564.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,564.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,564.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1051.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,564.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,564.16,5022.7,
VISTASEQ 6,2801106,CDM,301,RC,81317,HCPCS,outpatient,,,1414,1060.5,,1131.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,707,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,707,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,707,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,338.25,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,777.7,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,879.45,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1060.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1060.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1060.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1060.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,568.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,568.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1060.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,568.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1082.4,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,676.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1014.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,338.25,1131.2,
EX PILONIDAL CYST,6200107,CDM,360,RC,11771,HCPCS,outpatient,,,1423,1067.25,,1138.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,572.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,782.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,572.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,572.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1067.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,572.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,572.62,3817.9,
INCISION OF RECTAL ABSCESS,6200554,CDM,510,RC,46045,HCPCS,outpatient,,,1426,1069.5,,1140.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,573.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,784.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,573.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,573.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1069.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,573.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,573.82,4526.47,
Bone Bx Superficial Radiology,4001157,CDM,510,RC,20220,HCPCS,outpatient,,,1428,1071,,1142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,785.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,574.63,2216.25,
BONE BIOPSY DEEP PERCUTANEOUS,4200070,CDM,320,RC,20225,HCPCS,outpatient,,,1428,1071,,1142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,785.4,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,574.63,2216.25,
AMPUTATION METATARSAL WITH TOE SINGLE,6200051,CDM,360,RC,28810,HCPCS,outpatient,,,1428,1071,,1142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,785.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,574.63,4399.33,
RHINOSCOPY REMOVAL FOREIGN BODY,6200281,CDM,360,RC,30320,HCPCS,outpatient,,,1428,1071,,1142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,785.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1071,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,574.63,3047.65,
FLEBOGAMMA 5%  10GM/200ML,3202776,CDM,636,RC,J1572,HCPCS,both,,,1429.8,1072.35,,1143.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,575.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,786.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1143.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1072.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,575.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,575.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1072.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1143.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1143.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,575.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1143.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.12,1143.84,
EXC HIP PELVIS LESION SC 3CM>,6200559,CDM,360,RC,27043,HCPCS,outpatient,,,1430,1072.5,,1144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,786.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1072.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,575.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575.43,5022.7,
ER EXPLORATION PENETRATING WOUND NECK,1400079,CDM,450,RC,20100,HCPCS,outpatient,,,1434,1075.5,,1147.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,577.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,788.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,577.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,577.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1075.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,577.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,632.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,393.99,1147.2,
MSLT,5600020,CDM,740,RC,95805,HCPCS,outpatient,,,1436,1077,,1148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,577.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,789.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,416.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,577.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,577.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1077,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,577.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,714.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,446.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,669.81,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,416.95,1360.5,
POLYSOMNOGRAM,200002,CDM,510,RC,95810,HCPCS,outpatient,,,1442,1081.5,,1153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,793.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,580.26,1380.94,
POLYSOMNOGRAM  <6,5200105,CDM,920,RC,95782,HCPCS,outpatient,,,1442,1081.5,,1153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2131,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2131,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2131,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,793.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1081.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,580.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,580.26,2131,
OCCUPATIONAL MEDICINE PROFILE/FEMALE,2800456,CDM,300,RC,87902,HCPCS,outpatient,,,1449,1086.75,,1159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,796.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,411.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.72,1159.2,
OCCUPATIONAL MEDICINE PROFILE/MALE,2800457,CDM,300,RC,87902,HCPCS,outpatient,,,1449,1086.75,,1159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,796.95,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,411.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.72,1159.2,
BIOPSY/REMOVAL OF LYMPH,6200376,CDM,360,RC,38525,HCPCS,outpatient,,,1449,1086.75,,1159.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,583.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,796.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,583.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,583.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1086.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1159.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,583.08,5080.87,
HIV GENOSURE,2800355,CDM,301,RC,87901,HCPCS,outpatient,,,1450,1087.5,,1160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,909.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,128.72,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,797.5,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,334.69,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,411.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,386.17,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.72,1160,
INSERTION PICC W/RAD SUPERVISION AND INT,6200608,CDM,360,RC,36573,HCPCS,outpatient,,,1450,1087.5,,1160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,583.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3484.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3484.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3484.31,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,797.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,583.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,583.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1087.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,583.48,3484.31,
EXC TUMOR ABD WALL 3CM OR GREATER,6200132,CDM,360,RC,22903,HCPCS,outpatient,,,1453,1089.75,,1162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,584.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,799.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,584.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,584.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1089.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,584.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,584.69,5022.7,
CT ABD AND PELVIS WO CONTRAST,4300002,CDM,352,RC,74176TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT ABDOMEN WITHOUT,4300007,CDM,352,RC,74150TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT BRAIN WITHOUT,4300010,CDM,351,RC,70450TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT CHEST WITHOUT,4300013,CDM,352,RC,71250TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT C-SPINE WITHOUT,4300015,CDM,352,RC,72125TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT LOWER EXT WITHOUT RT,4300023,CDM,352,RC,73700TCRT,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT L-SPINE WITHOUT,4300027,CDM,352,RC,72131TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT NECK WITHOUT,4300030,CDM,351,RC,70490TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT ORBITS WITHOUT,4300033,CDM,351,RC,70480TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT PELVIS WITHOUT,4300036,CDM,352,RC,72192TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT T-SPINE WITHOUT,4300042,CDM,352,RC,72128TC,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT UPPER EXT WITHOUT RT,4300045,CDM,352,RC,73200TCRT,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT LOWER EXT WITHOUT LT,4300062,CDM,352,RC,73700TCLT,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT UPPER EXT WITHOUT LT,4300066,CDM,352,RC,73200TCLT,HCPCS,outpatient,,,1473,1104.75,,1178.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1178.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1178.4,
CT SINUSES WITHOUT,4300039,CDM,351,RC,70486TC,HCPCS,outpatient,,,1476,1107,,1180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,738,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,738,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,738,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1180.8,
EXC NECK LESION SC 3CM>,6200457,CDM,360,RC,21552,HCPCS,outpatient,,,1476,1107,,1180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,811.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1107,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,593.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,593.94,5022.7,
UMBIL HERNIA REPAIR 5YRS OR OLDERREDUC,6200368,CDM,510,RC,49585,HCPCS,outpatient,,,1477,1107.75,,1181.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,594.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,812.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,594.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,594.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1107.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,594.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1181.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,594.34,5430.82,
BIOPSY OF LIVER NEEDLE PERCUTANEOUS,6200065,CDM,360,RC,47000TC,HCPCS,outpatient,,,1494,1120.5,,1195.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,601.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,821.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,601.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1120.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,601.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,601.19,1195.2,
OBSERVATION-DIRECT ADMIT INITIAL HOUR,300003,CDM,762,RC,G0379,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,992.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,992.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,992.53,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,,,,other,Not separately reimbursable for outpatient setting,1500,,,,other,Not separately reimbursable for outpatient setting,1500,,,,other,Not separately reimbursable for outpatient setting,1500,,,,other,Not separately reimbursable for outpatient setting,1500,,,,other,Not separately reimbursable for outpatient setting,1500,,,,other,Not separately reimbursable for outpatient setting,1500,,,,other,Not separately reimbursable for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,472.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,506.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,759.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,472.73,1500,
STENT SIROLIMUS ELUTING CORONARY SYSTEM,5890083,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY SYSTEM,5890085,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY,5890088,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SYS SIROLIMUS ELUTING CORONARY,5890089,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SYS SIROLIMUS ELUTING CORONARY,5890093,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT ORSIRO MISSION ELUTING 3.5,5890095,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING 2.25 MM,5890096,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY SYSTEM,5890099,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY SYSTEM,5890100,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY SYSTEM,5890101,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY,5890109,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY,5890110,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SYS SIROLIMUS ELUTING CORONARY,5890112,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SYSTEM ORSIRO DRUG-ELUTING 453945,5890122,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SYSTEM ORSIRO DRUG ELUTING  453934,5890123,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT ORSIRO MISSION ELUTING CORONARY,5890124,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY,5890126,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY,5890127,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY,5890130,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY 453927,5890133,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY 453936,5890134,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY 453955,5890135,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY 453930,5890138,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
STENT SIROLIMUS ELUTING CORONARY,5890144,CDM,278,RC,C1874,HCPCS,both,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1050,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1200,
REPAIR BLADDER & VAGINA,6100119,CDM,521,RC,57240,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,6850.42,
REPAIR RECTUM & VAGINIA,6100120,CDM,521,RC,57250,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,6850.42,
PARTIAL HYSTERECTOMY,6100145,CDM,521,RC,58180,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,3218.62,
UNSP VAGINAL HYSTERECTOMY,6100147,CDM,521,RC,58260,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,6850.42,
SALPINGO-OOPHORECTOMY,6100159,CDM,969,RC,58720,HCPCS,outpatient,,,1500,1125,,,,,,other,Not separately reimbursable for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,900,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1192.51,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1043.45,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,467.68,1192.51,
OVARIAN CYSTECTOMY,6100161,CDM,521,RC,58925,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,6850.42,
EXCISION OF SPERMATIC CORD,6200156,CDM,360,RC,55520,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2764.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4736.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2960.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,4736.99,
UNLISTED PROC ABD PERITONEUM & OMENTUM,6200312,CDM,360,RC,49999,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,4264.84,
LAP EXC COLON WITH SPLENIC FLEXURE,6200389,CDM,360,RC,44213,HCPCS,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,6043.61,
SALPINGO-OOPHORECTOMY,6300175,CDM,972,RC,58720,HCPCS,outpatient,,,1500,1125,,,,,,other,Not separately reimbursable for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,900,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,467.68,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1192.51,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,745.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1043.45,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,467.68,1192.51,
CTA ABD  AORTA W RUNOFF,4300047,CDM,352,RC,75635TC,HCPCS,outpatient,,,1504,1128,,1203.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,605.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,752,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,752,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,752,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1128,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1128,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1128,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1128,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,605.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1128,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,605.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1203.2,
BX MUSCLE PERQ NEEDLE,4000213,CDM,360,RC,20206,HCPCS,outpatient,,,1509,1131.75,,1207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,607.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,829.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,607.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,607.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,607.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,607.22,2216.25,
PLATE NARROW L DR (54-25374),890099,CDM,278,RC,C1713,HCPCS,both,,,1515.8,1136.85,,1212.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,757.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,757.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1212.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,609.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,609.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1061.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1212.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1212.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,609.96,1212.64,
EXCISION BREAST LESION W/RAD MARKER PLCM,6200141,CDM,360,RC,19125,HCPCS,outpatient,,,1517,1137.75,,1213.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,610.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,834.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1213.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,610.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,610.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1213.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1137.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1213.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1213.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,610.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1213.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,610.44,5080.87,
CTA ABD & PELVIS W/WO CONTRAST,4300046,CDM,352,RC,74174TC,HCPCS,outpatient,,,1528,1146,,1222.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,614.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,764,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,764,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,764,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1146,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,614.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,614.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1146,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,614.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1222.4,
REMOVAL ANAL FISTULA COMPLEX,6200461,CDM,360,RC,46280,HCPCS,outpatient,,,1532,1149,,1225.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,616.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,842.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1225.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,616.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,616.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1225.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1149,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1225.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1225.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,616.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1225.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,616.48,4526.47,
ER CARDIOVERSION EXTERNAL,1400019,CDM,450,RC,92960,HCPCS,outpatient,,,1544,1158,,1235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1042.65,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,849.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,507.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,543.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,507.25,1235.2,
S&I INJ PULM/GRAFT,5800175,CDM,480,RC,93456,HCPCS,outpatient,,,1544,1158,,1235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,849.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1158,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,621.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,621.31,8687.74,
EXC SOFT TISSUE TUMOR BACK/FLANK3CM OR>,6200130,CDM,360,RC,21931,HCPCS,outpatient,,,1554,1165.5,,1243.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,625.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,854.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,625.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,625.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,625.33,5022.7,
US CORE BX BREAST  ABRAHA,4100017,CDM,360,RC,19083,HCPCS,outpatient,,,1555,1166.25,,1244,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,855.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,625.73,2216.25,
US NEEDLE LOC BREAST  ABRAHA,4100060,CDM,360,RC,19285,HCPCS,outpatient,,,1555,1166.25,,1244,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,855.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,313.02,1244,
I & D RECTAL ABSCESS WITH FISTULOTOMY,6200184,CDM,360,RC,46060,HCPCS,outpatient,,,1555,1166.25,,1244,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,855.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1166.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,625.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,625.73,4526.47,
HEMORRHOIDECTOMY INT & EXT 2 OR MORE GRP,6200180,CDM,360,RC,46260,HCPCS,outpatient,,,1564,1173,,1251.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,860.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1173,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,629.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,629.35,4526.47,
SUSPEND TESTIS,6200366,CDM,510,RC,54640,HCPCS,outpatient,,,1568,1176,,1254.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,630.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,862.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,630.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,630.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1176,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,630.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,630.96,5430.82,
ER EXPLORATION PENETRATING WOUND EXTREM,1400078,CDM,450,RC,20103,HCPCS,outpatient,,,1570,1177.5,,1256,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,631.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,863.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,631.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,631.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1177.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,631.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,631.77,2216.25,
RPR UMBILICAL HERNIA BLOCK 5 YRSPLUS,6200282,CDM,360,RC,49587,HCPCS,outpatient,,,1579,1184.25,,1263.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,635.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,868.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,635.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,635.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1184.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,635.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,635.39,5430.82,
PR US PARACENTESIS-RADIOLOGY,4010138,CDM,972,RC,49083,HCPCS,outpatient,,,1582,1186.5,,,,,,other,Not separately reimbursable for physician setting,200.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,949.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,102.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,102.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,200.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,200.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,102.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,102.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,200.05,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,164.38,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,102.74,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,143.84,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,102.74,949.2,
POLYSOMNOGRAM HST,5200104,CDM,920,RC,95800,HCPCS,outpatient,,,1588,1191,,1270.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,328.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,328.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,328.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,873.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,639.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,639.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,639.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.43,1270.4,
"Myomectomy, excision of fibroid tumor(s)",6100729,CDM,982,RC,58145,HCPCS,outpatient,,,1593,1194.75,,,,,,other,Not separately reimbursable for physician setting,352.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,557.9,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,955.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,557.9,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,557.9,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,557.9,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,352.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,352.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,557.9,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,557.9,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,352.04,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,892.64,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,557.9,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,781.06,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,352.04,955.8,
EXC TUMOR FACE/SCALP SUBFAS 2CM>,6200624,CDM,360,RC,21014,HCPCS,outpatient,,,1600,1200,,1280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1761.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,880,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,643.84,3817.9,
RPR UMBILICAL HERNIA BLOCK UNDER5 YRS,6200283,CDM,360,RC,49582,HCPCS,outpatient,,,1605,1203.75,,1284,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,645.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,882.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,645.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1203.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,645.85,5430.82,
ADJACENT TISSUE TRANSFER/REARRANGTRUNK,6200048,CDM,360,RC,14000,HCPCS,outpatient,,,1617,1212.75,,1293.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,650.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2559.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2559.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2559.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,889.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,650.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,650.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1212.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,650.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,650.68,2559.11,
PRIVIGEN INTRAVENOUS SOLUTION 10% 10GM,3203206,CDM,636,RC,J1459,HCPCS,both,,,1620,1215,,1296,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,651.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,891,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1215,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,651.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,651.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1215,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,651.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.38,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.59,1296,
GAMMAKED 10% 10GM/100ML,3206564,CDM,636,RC,J1561,HCPCS,both,,,1650,1237.5,,1320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,907.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,663.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.26,1320,
NM LOCALIZATION-GALLIUM WHOLE BODY,4400016,CDM,341,RC,78806TC,HCPCS,outpatient,,,1662,1246.5,,1329.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,668.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,831,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,831,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,831,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,914.1,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,668.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,668.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1246.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,668.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,668.79,1329.6,
LIVER BX RADIOLOGY,4000217,CDM,320,RC,47000,HCPCS,outpatient,,,1686,1264.5,,1348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,927.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,678.45,2216.25,
BX LUNG/MED PERQ,4001152,CDM,360,RC,32405,HCPCS,outpatient,,,1686,1264.5,,1348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,843,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,843,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,843,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,927.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,678.45,1348.8,
Bx Abd/Retro Per Pqx Need,4200083,CDM,320,RC,49180,HCPCS,outpatient,,,1686,1264.5,,1348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,927.3,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,678.45,2216.25,
Bx Lung Perqut,4200084,CDM,360,RC,32408,HCPCS,outpatient,,,1686,1264.5,,1348.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1899.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1899.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1899.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,927.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1264.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,678.45,2216.25,
INJ CHOLANGIOGRAPHY THRU T-TUBE,400088,CDM,490,RC,47505,HCPCS,outpatient,,,1687,1265.25,,1349.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,843.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,843.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,843.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,927.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,678.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1265.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,678.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,678.85,1349.6,
COLON/POLYP/BIOPSY,400016,CDM,490,RC,45384,HCPCS,outpatient,,,1689,1266.75,,1351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,928.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1622.75,
COLON/W BIOPSY BY SNARE TECHNIQUE,400017,CDM,490,RC,45385,HCPCS,outpatient,,,1689,1266.75,,1351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,928.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1622.75,
COLONSCOPY W BX/POLYPECTOMY W HOT BX,400020,CDM,490,RC,45384,HCPCS,outpatient,,,1689,1266.75,,1351.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,928.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1266.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1622.75,
ORENCIA INTRAVENOUS PWD FOR SOLN 250MG,3202777,CDM,636,RC,J0129,HCPCS,both,,,1698.88,1274.16,,1359.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,683.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,934.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,849.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1359.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1274.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1274.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1274.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1274.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,42.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,683.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,683.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1359.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1274.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1359.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1359.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68.31,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,42.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,64.05,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1359.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.7,1359.1,
REMDESIVIR 200MG/NSS 250ML IVPB,3206169,CDM,636,RC,J0248,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.69,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9.08,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.06,1360,
INITIAL HOSPITAL CARE-OBS-LEVEL 1,6200536,CDM,510,RC,99218,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,164.3,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,164.3,164.3,
VASCUTRAK,5800193,CDM,278,RC,C1725,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,684.08,1360,
STENT ELUNIR 2.75X20 DRUG COATED,5890012,CDM,275,RC,C1874,HCPCS,outpatient,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
STENT ELUNIR 2.75X12 DRUG ELUTING,5890013,CDM,278,RC,C1874,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
STENT RIDAFOROLIMUS ELUTING CORONARY,5890017,CDM,278,RC,C1874,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
STENT RIDAFOROLIMUS ELUTING CORONARY,5890024,CDM,278,RC,C1874,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
ELUNIR ELUTING CORONARY STENT SYSTEM,5890028,CDM,278,RC,C1874,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
EMERGENCY ROOM,6200549,CDM,450,RC,99282,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,189.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,206.44,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,129.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,193.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,120.48,206.44,
STENT ELUNIR RIDAFOROLIMUS ELUTING CORON,5890042,CDM,278,RC,C1874,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
STENT ELUNIR RIDAFOROLIMUS ELUTING CORON,5890049,CDM,278,RC,C1874,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
STENT ELUNIR RIDAFOROLIMUS ELUT CORONARY,5890055,CDM,278,RC,C1874,HCPCS,both,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1360,
INTERRUPTION OF INFERIOR VENA CAVA VEIN,6200196,CDM,360,RC,37620,HCPCS,outpatient,,,1700,1275,,1360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1275,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,684.08,1360,
"Excision, benign lesion 1.1 - 2.0cm",6100577,CDM,521,RC,11422,HCPCS,outpatient,,,1701,1275.75,,1360.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,684.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1316.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,935.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,684.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1360.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1275.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1360.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,684.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1360.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,684.48,2216.25,
LAPAROSCOPY RETROPERITONEAL LYMPH BIOPSY,6200604,CDM,360,RC,38570,HCPCS,outpatient,,,1710,1282.5,,1368,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,688.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,940.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,688.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,688.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1282.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,688.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,688.1,8162.33,
PLACMT OF BREAST LOC DEV; FIRST LESION,4001153,CDM,402,RC,19285,HCPCS,outpatient,,,1719,1289.25,,1375.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,691.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,313.02,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,945.45,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,691.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,691.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1289.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,691.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1375.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,313.02,1375.2,
PR PLCMT OF BREAST LOC DEV; FIRST LESION,4011153,CDM,972,RC,19285,HCPCS,outpatient,,,1719,1289.25,,,,,,other,Not separately reimbursable for physician setting,304.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1031.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,82.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,82.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,304.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,304.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,82.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,304.22,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,132.78,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,82.99,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,116.19,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,82.99,1031.4,
BLOCK TRIATHLON TIBIAL AUGMENT HALF,890244,CDM,278,RC,C1776,HCPCS,both,,,1723.92,1292.94,,1379.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,693.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,948.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,861.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,861.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,861.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,861.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,861.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,861.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1379.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1292.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1292.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1292.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1292.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,693.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1206.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1292.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1379.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1379.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,693.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1379.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1379.14,
OOPHORECTOMY,6200220,CDM,360,RC,58940,HCPCS,outpatient,,,1725,1293.75,,1380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,694.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5532.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5532.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5532.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1725,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,948.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1725,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1725,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,694.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,694.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1725,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1725,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,694.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1725,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1725,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1725,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,694.14,5532.88,
EXPLORATION POSTOPERATIVE HEMORRHAGE EXT,6200623,CDM,360,RC,35860,HCPCS,outpatient,,,1730,1297.5,,1384,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,696.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4419.64,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.64,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.64,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,951.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,696.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,696.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1297.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,696.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,696.15,4419.64,
PRP I/HERN INIT REDUC>5,6200239,CDM,360,RC,49505,HCPCS,outpatient,,,1735,1301.25,,1388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,698.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,954.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,698.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,698.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1301.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,698.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,698.16,5430.82,
EXC NECK TUMOR DEEP <5CM,6200126,CDM,360,RC,21556,HCPCS,outpatient,,,1742,1306.5,,1393.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,700.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,958.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,700.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,700.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1306.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,700.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,700.98,3817.9,
XR MYELOGRAM CERVICAL,4000094,CDM,320,RC,62302,HCPCS,outpatient,,,1747,1310.25,,1397.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,702.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,960.85,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,702.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,702.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1310.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1094.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1026.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,638.88,1957.1,
FBR:MUSCLE SIMPLE,1400164,CDM,450,RC,20520,HCPCS,outpatient,,,1748,1311,,1398.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,703.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,703.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,703.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1311,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,703.4,2216.25,
EXC SHOULDER TUMOR SOFT TISSUE <5CM,6200127,CDM,360,RC,23076,HCPCS,outpatient,,,1770,1327.5,,1416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,973.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1327.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,712.25,3817.9,
ORBACTIV 400 MG VIAL,3204897,CDM,636,RC,J2407,HCPCS,both,,,1792.5,1344.38,,1434,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,721.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,985.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1434,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1344.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1344.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1344.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1344.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,721.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,721.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1434,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1344.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1434,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,721.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,27.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41.31,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1434,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.54,1434,
XR VENOGRAM EXTREMITY BILATERAL,4000132,CDM,320,RC,75822TC,HCPCS,outpatient,,,1800,1350,,1440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,990,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,724.32,1440,
ER CRITICAL CARE 1ST 30-74 MIN,1400051,CDM,450,RC,99291,HCPCS,outpatient,,,1815,1361.25,,1452,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1225.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1225.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1225.38,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,662.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,662.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1134.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,709.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1063.72,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,662.14,1815,
ER CRITICAL CARE 1ST 30-74 MIN MODIFIER,1400052,CDM,450,RC,9929125,HCPCS,outpatient,,,1815,1361.25,,1452,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,907.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,907.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,907.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1361.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,730.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,730.36,1452,
PARACENTESIS WITH IMAGING GUID-RAD,4000138,CDM,320,RC,49083,HCPCS,outpatient,,,1820,1365,,1456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,732.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1228.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1228.27,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1001,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,732.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,732.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1365,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,732.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,711.98,1456,
MINI VISION-SMALL BARE METAL STENTS,5800106,CDM,278,RC,C1877,HCPCS,both,,,1830,1372.5,,1464,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,736.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1372.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,736.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1281,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1372.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,736.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,736.39,1464,
PLATE INTERMEDIATE LONG DR,890161,CDM,278,RC,C1713,HCPCS,both,,,1830.4,1372.8,,1464.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,736.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,915.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1464.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1372.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,736.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,736.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1281.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1372.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1464.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1464.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,736.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1464.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,736.55,1464.32,
BIOPSY REMOVAL INTERNAL MAMMARY OPEN,6200546,CDM,360,RC,38530,HCPCS,outpatient,,,1832,1374,,1465.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,737.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1007.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,737.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,737.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1374,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,737.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1465.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,737.2,5080.87,
EXC HYDROCELE SPERMATIC CORD W/HERNIARE,6200115,CDM,360,RC,55540,HCPCS,outpatient,,,1842,1381.5,,1473.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1013.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,741.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,741.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1381.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,741.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,741.22,5430.82,
EXCISION OF LINGUAL TONSIL,6200383,CDM,360,RC,42870,HCPCS,outpatient,,,1846,1384.5,,1476.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,742.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4147.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4147.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4147.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1015.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,742.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,742.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1384.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,742.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7891.73,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,742.83,7891.73,
POLYSOMNOGRAM W/CPAP,200001,CDM,510,RC,95811,HCPCS,outpatient,,,1850,1387.5,,1480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1017.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,744.44,1480,
CT BRAIN WITH & WO,4300009,CDM,351,RC,70470TC,HCPCS,outpatient,,,1850,1387.5,,1480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,925,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,925,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,925,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1480,
POLYSOMNOGRAM SPLIT NIGHT <6,5200102,CDM,920,RC,95783,HCPCS,outpatient,,,1850,1387.5,,1480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2218.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2218.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2218.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1017.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,744.44,2218.91,
POLYSOMNOGRAM W/CPAP <6,5200103,CDM,920,RC,95783,HCPCS,outpatient,,,1850,1387.5,,1480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2218.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2218.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2218.91,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1017.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1387.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,744.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,744.44,2218.91,
MASTECTOMY MODIFIED RADICAL,6200392,CDM,360,RC,19307,HCPCS,outpatient,,,1852,1389,,1481.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,745.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7579.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7579.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7579.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1018.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,745.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,745.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1389,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,745.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8783.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1481.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,745.24,8783.64,
PLATE SHORT INTERMEDIATE LEFT,890198,CDM,278,RC,C1713,HCPCS,both,,,1854,1390.5,,1483.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,746.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1019.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,927,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,927,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,927,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,927,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,927,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,927,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1483.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1390.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1390.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1390.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1390.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,746.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1297.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1390.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1483.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1483.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,746.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1483.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,746.05,1483.2,
THORACENTESIS W/O IMAGING TECHNICAL,7000040,CDM,761,RC,32554,HCPCS,outpatient,,,1860,1395,,1488,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,748.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1023,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,748.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,748.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1395,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,498.94,1488,
INSERT SWAN GANZ,5800085,CDM,480,RC,93503,HCPCS,outpatient,,,1866,1399.5,,1492.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1743.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1743.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1743.04,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1026.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,750.88,2198.94,
STENT SYSTEM CORONARY 1007850-15,90006326,CDM,278,RC,C1874,HCPCS,both,,,1866,1399.5,,1492.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1026.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1306.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1492.8,
XR MYELOGRAM LUMBAR,4000095,CDM,320,RC,62304,HCPCS,outpatient,,,1870,1402.5,,1496,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,752.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1957.1,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1028.5,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,638.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,752.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,752.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1402.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,752.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1094.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,684.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1026.35,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,638.88,1957.1,
REMOVAL OF PILONDIAL LESION,6200252,CDM,360,RC,11772,HCPCS,outpatient,,,1875,1406.25,,1500,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1031.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,754.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,754.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1406.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,754.5,3817.9,
DRAINAGE OF SCROTUM ABSCESS,6200096,CDM,360,RC,55100,HCPCS,outpatient,,,1880,1410,,1504,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1034,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,756.51,3089.62,
EXC ABDOMINAL SUBFACIAL <5CM,6200602,CDM,360,RC,22900,HCPCS,outpatient,,,1880,1410,,1504,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1034,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1410,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,756.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,756.51,3817.9,
MASTECTOMY SUBCUTANEOUS,6200208,CDM,360,RC,19304,HCPCS,outpatient,,,1886,1414.5,,1508.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,758.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,943,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,943,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,943,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1037.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,758.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,758.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1414.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,758.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1508.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,758.93,1508.8,
INC BONE CORTEX (OSTEO/BONE ABSC) FOOT,6200519,CDM,360,RC,28005,HCPCS,outpatient,,,1904,1428,,1523.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,766.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3780.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1047.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1523.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,766.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,766.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1523.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1428,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1523.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1523.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,766.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1523.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,766.17,4399.33,
REPAIR ING HERNIA SLIDING,6200405,CDM,360,RC,49525,HCPCS,outpatient,,,1912,1434,,1529.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,769.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1051.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,769.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,769.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1434,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,769.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,769.39,5430.82,
STEM TRIATHLON TOTAL KNEE CEMENTED,890245,CDM,278,RC,C1776,HCPCS,both,,,1912.24,1434.18,,1529.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,769.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1051.73,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,956.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,956.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,956.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,956.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,956.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,956.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1434.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,769.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,769.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1338.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1434.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1529.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,769.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1529.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1529.79,
REVISION OF SKIN POCKET,5800165,CDM,480,RC,33222,HCPCS,outpatient,,,1916,1437,,1532.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1053.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,771,3449.93,
REVISION-SKIN POCKET ICD SINGLE OR DUAL,5800166,CDM,480,RC,33223,HCPCS,outpatient,,,1916,1437,,1532.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1053.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1437,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,771,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,771,3449.93,
UNIL FEMORAL HERNIA INIT REDUCTION,6200435,CDM,360,RC,49550,HCPCS,outpatient,,,1924,1443,,1539.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1058.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,774.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,774.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1443,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,774.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,774.22,5430.82,
LAPAROSCOPY GASTROSTOMY,6200607,CDM,360,RC,43653,HCPCS,outpatient,,,1930,1447.5,,1544,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,776.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1061.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,776.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,776.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1447.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,776.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,776.63,8162.33,
ER FEED TUBE REPOSITIONING,1400088,CDM,450,RC,43761,HCPCS,outpatient,,,1943,1457.25,,1554.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1311.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1311.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1311.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,185.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,198.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,297.7,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,185.32,1554.4,
AMPUTATION FOLLOWUP SURGERY,6200518,CDM,360,RC,27884,HCPCS,outpatient,,,1943,1457.25,,1554.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1068.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1457.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,781.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1554.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,781.86,4399.33,
THORACENTESIS WO IMAGING,1400210,CDM,450,RC,32554,HCPCS,outpatient,,,1946,1459.5,,1556.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,783.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,783.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,783.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1459.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,498.94,1556.8,
FERAHEME 510 MG (30MG/ML) 17 ML VIAL,3206011,CDM,636,RC,Q0138,HCPCS,both,,,1950,1462.5,,1560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1072.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,0.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,0.75,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.5,1560,
HERNIA REPAIR STRANGULATED/INCARCERATED,6200182,CDM,360,RC,49507,HCPCS,outpatient,,,1955,1466.25,,1564,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,786.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1075.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,786.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1466.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,786.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,786.69,5430.82,
COLON/FLEXIBLE W/ ABLATION,400168,CDM,490,RC,45385,HCPCS,outpatient,,,1959.58,1469.69,,1567.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1077.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.3,100,,,fee schedule,100% LA Medicaid ASC fee schedule for outpatient setting,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,468.3,1622.75,
COLONOSCOPY FLEXIBLE W/ ABLATION,6200603,CDM,510,RC,45385,HCPCS,outpatient,,,1959.58,1469.69,,1567.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,788.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1622.75,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1077.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,788.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,788.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1469.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,788.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1567.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,788.53,1622.75,
DEBRIDE GENITALIA AND PERINEUM,6200556,CDM,510,RC,11004,HCPCS,outpatient,,,1964,1473,,1571.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,790.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,982,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,982,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,982,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1964,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1080.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1964,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1964,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1964,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,790.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,790.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1964,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1964,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1473,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,790.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1964,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1964,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1964,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,790.31,1964,
EXC RECTAL TUMOR TRANSANAL APPROACH,6200501,CDM,360,RC,45171,HCPCS,outpatient,,,1968,1476,,1574.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4526.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4526.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1082.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2216.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,791.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3797.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2373.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1574.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,791.92,4526.48,
US CORE BX BREAST ADD ON,4001080,CDM,320,RC,19084,HCPCS,outpatient,,,1977,1482.75,,1581.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1087.35,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1482.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,1581.6,
PR US CORE BX BREAST ADD ON,4011080,CDM,972,RC,19084,HCPCS,outpatient,,,1977,1482.75,,,,,,other,Not separately reimbursable for physician setting,349,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,76.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1186.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,76.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,76.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,76.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,349,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,349,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,76.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,76.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,349,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,121.65,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,76.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,106.44,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,76.03,1186.2,
PACEMAKER LEADS,5800110,CDM,278,RC,C1779,HCPCS,both,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
TOTAL HYSTERECTOMY,6100144,CDM,521,RC,58150,HCPCS,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2000,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2000,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,3218.62,
EXTENSIVE HYSTERECTOMY,6100146,CDM,521,RC,58210,HCPCS,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2000,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2000,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,2000,
VAG HYST INCLUDING T/O,6100148,CDM,521,RC,58262,HCPCS,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4054.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4054.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4054.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,6850.42,
TOTAL HYSTERECTOMY,6300172,CDM,972,RC,58150,HCPCS,outpatient,,,2000,1500,,,,,,other,Not separately reimbursable for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1200,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1599.92,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1399.93,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,647.11,1599.92,
STENT BARE METAL 2.25X15 W/DELIVERY SYST,90007126,CDM,278,RC,C1876,HCPCS,both,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
STENT BARE METAL 2.5X8MM W/DELIVERY SYST,90007127,CDM,278,RC,C1876,HCPCS,both,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
STENT GUIDING NIRXCELL 2.5X12MM,90007129,CDM,278,RC,C1876,HCPCS,both,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
STENT GUIDING NIRXCELL 2.75X24,90007131,CDM,278,RC,C1876,HCPCS,both,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
APPENDECTOMY LAPAROSCOPY,6200060,CDM,360,RC,44970,HCPCS,outpatient,,,2010,1507.5,,1608,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,808.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1105.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,808.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,808.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1507.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,808.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,808.82,8162.33,
REP COMP 2.6-7.5CM SCALP ARM LEGS,1400047,CDM,450,RC,13121,HCPCS,outpatient,,,2024,1518,,1619.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,501.05,1619.2,
ER DEBRIDE ECZEMATOUS/INFECT SKIN TO 10%,1400055,CDM,450,RC,11000,HCPCS,outpatient,,,2024,1518,,1619.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,501.05,1619.2,
REP COMP 2.6-7.5 CM-FACE MOUTH NEC,1400282,CDM,450,RC,13132,HCPCS,outpatient,,,2024,1518,,1619.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1365.74,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1518,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,814.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,501.05,1619.2,
AMPUTATION OF LOWER LEG,6200052,CDM,360,RC,27882,HCPCS,outpatient,,,2032,1524,,1625.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,817.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1016,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1016,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1016,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2032,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1117.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2032,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2032,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2032,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,817.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,817.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2032,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2032,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1524,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,817.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2032,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2032,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2032,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,817.68,2032,
FINGER AMPUTATION W/DIRECT CLOSURE,6200171,CDM,360,RC,26951,HCPCS,outpatient,,,2034,1525.5,,1627.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,818.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1118.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,818.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,818.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1525.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,818.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,818.48,4399.33,
SKIN TISSURE REARRANGEMENT,6200039,CDM,510,RC,14040,HCPCS,outpatient,,,2041,1530.75,,1632.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,821.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2559.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2559.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2559.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1122.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,821.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,821.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1530.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,821.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1632.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,821.3,2559.11,
EXPLORATION OF PENETRATING WOUNDNECK,6200167,CDM,360,RC,20100,HCPCS,outpatient,,,2042,1531.5,,1633.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,821.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,903.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1123.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1633.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,821.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,821.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1633.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1531.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1633.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1633.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,821.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,632.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1633.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,393.99,1633.6,
DRAINAGE OF PELVIS LESION,6200567,CDM,360,RC,26990,HCPCS,outpatient,,,2043,1532.25,,1634.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,822.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1123.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,822.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,822.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1532.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,822.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,822.1,4399.33,
EXCISION TUMOR THIGH KNEE DEEP,6200339,CDM,510,RC,27328,HCPCS,outpatient,,,2048,1536,,1638.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,824.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1126.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1638.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,824.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,824.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1638.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1536,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1638.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,824.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1638.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,824.12,3817.9,
REV OF COLOSTOMY,6200484,CDM,360,RC,44340,HCPCS,outpatient,,,2074,1555.5,,1659.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,834.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1140.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2805.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2805.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2805.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,834.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,834.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1555.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,834.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4807.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4507.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,834.58,4807.8,
GAMMAGARD 10% 10 GM 100ML,3208081,CDM,636,RC,J1569,HCPCS,both,,,2076,1557,,1660.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1141.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1038,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.46,1660.8,
INJ ANEST AGNT TRANSFORAMINAL W/GUIDANCE,7200071,CDM,360,RC,64483,HCPCS,outpatient,,,2076,1557,,1660.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1140.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1140.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1140.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1141.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,734.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1557,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,835.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1259.46,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,787.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1180.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1660.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,734.99,1660.8,
NM BRAIN-SPECT,4400008,CDM,341,RC,78607TC,HCPCS,outpatient,,,2080,1560,,1664,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,836.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1040,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1040,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1040,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1040,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1144,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,836.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,836.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1560,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,836.99,1664,
FINE NEEDLE ASP IN RAD.**,4000214,CDM,360,RC,10005,HCPCS,outpatient,,,2100,1575,,1680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1155,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,559.72,1845.77,
EV3 STENT,5800069,CDM,270,RC,C1876,HCPCS,outpatient,,,2100,1575,,1680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1155,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,845.04,1680,
"Laparoscopy, total hyster uterus >250g",6100727,CDM,982,RC,58572,HCPCS,outpatient,,,2100,1575,,,,,,other,Not separately reimbursable for physician setting,749.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1024.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1260,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1024.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1024.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1024.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,749.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,749.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1024.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1024.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,749.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1638.91,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,1024.32,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1434.05,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,749.99,1638.91,
SKIN TISSUE REARRANGMENT,6200290,CDM,360,RC,14001,HCPCS,outpatient,,,2119,1589.25,,1695.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,852.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1165.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,852.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,852.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1589.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,852.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1695.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,852.69,3449.93,
LACERATION SKIN OVER 30.0 CM,1400135,CDM,450,RC,12037,HCPCS,outpatient,,,2121,1590.75,,1696.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1060.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,853.49,2550.71,
PR EXCISION BENIGN LESION,6210008,CDM,982,RC,11401,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.48,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,83.48,83.48,
NEW OFFICE VISIT-BRIEF- PRO FEE,6210021,CDM,982,RC,99202,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,42.77,42.77,
NEW OFFICE VISIT-COMPREHENSIVE,6210022,CDM,982,RC,99205,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,122.19,122.19,
NEW OFFICE VISIT-INTERMEDIATE- PRO FEE,6210023,CDM,982,RC,99204,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,96.56,96.56,
NEW OFFICE VISIT-LIMITED- PRO FEE,6210024,CDM,982,RC,99203,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,62.18,62.18,
OFFICE VISIT- LVL II- PRO FEE,6210032,CDM,982,RC,99212,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,24.83,24.83,
OFFICE VISIT- LVL V- PRO FEE,6210033,CDM,982,RC,99215,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,84.93,84.93,
OFFICE VISIT- LVL IV- PRO FEE,6210034,CDM,982,RC,99214,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,62.65,62.65,
OFFICE VISIT- LVL III- PRO FEE,6210035,CDM,982,RC,99213,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,41.53,41.53,
LAC INTERM:N/H/F/EG OVER 30.0 CM,1400136,CDM,450,RC,12047,HCPCS,outpatient,,,2121,1590.75,,1696.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1060.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1590.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,853.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,853.49,2550.71,
PR EXCISION LESION,6210111,CDM,982,RC,11402,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,93.34,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,93.34,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,93.34,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,93.34,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,93.34,93.34,
PR EXCISION BENIGN CYS,6210138,CDM,982,RC,11441,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,95.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,95.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,95.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,95.63,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,95.63,95.63,
PR EXCISION BENIGN CYS,6210139,CDM,982,RC,11442,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,107.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,107.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,107.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,107.98,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,107.98,107.98,
PR OPEN INCISION BIOPSY,6210221,CDM,982,RC,19101,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,191.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,191.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,191.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,191.5,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,191.5,191.5,
FNA W/O IMAGE PRO FEE,6210342,CDM,982,RC,10021,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,83.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,83.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,83.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,83.99,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,83.99,83.99,
PR I&D OF ABCESS SIMPLE,6210347,CDM,982,RC,10060,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,65.58,65.58,
PR I&D REMOVAL OF FORE,6210349,CDM,982,RC,10120,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,79.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,79.56,79.56,
PROLIA 60MG/ML,3204334,CDM,636,RC,J0897,HCPCS,both,,,2130.39,1597.79,,1704.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,857.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1171.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1065.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1704.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1597.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1597.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1597.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1597.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,857.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,857.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1704.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1597.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1704.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1704.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,857.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,38.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,24.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,36.33,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1704.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.22,1704.31,
LAP WITH REMOV OF ADNEXAL STRUCTURES,6200202,CDM,360,RC,58661,HCPCS,outpatient,,,2135,1601.25,,1708,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,859.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1174.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,859.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,859.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1601.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,859.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1708,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,859.12,8162.33,
"AXILLARY LYMPHADENECTOMY, SUPERFICIAL",6200630,CDM,360,RC,38740,HCPCS,outpatient,,,2142,1606.5,,1713.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,861.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1178.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1713.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,861.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,861.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1713.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1606.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1713.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,861.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1713.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,861.94,7703.27,
BONE MARROW ASPIRATION,1400005,CDM,450,RC,38220,HCPCS,outpatient,,,2160,1620,,1728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,869.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,869.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1620,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,869.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,507.3,2216.25,
APPENDECTOMY-OPEN,6200324,CDM,510,RC,44950,HCPCS,outpatient,,,2161,1620.75,,1728.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,869.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1188.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,869.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1620.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,869.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1728.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.59,5234.76,
PARTIAL MASTECTOMY,6200223,CDM,360,RC,19301,HCPCS,outpatient,,,2170,1627.5,,1736,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,873.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1193.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,873.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,873.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1627.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,873.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,873.21,5080.87,
REOPEN OF FALLOPIAN TUBE,6100469,CDM,521,RC,58350,HCPCS,outpatient,,,2172,1629,,1737.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,874.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1194.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,874.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,874.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1629,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,874.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,874.01,6850.42,
HEP B AGES 20,6300008,CDM,972,RC,90746,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,112.61,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,70.38,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,98.53,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,70.38,112.61,
EXCIS BENIGN LESION-HEAD FT GEN 2.1-3.0,400045,CDM,360,RC,11423,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
HEPATITIS B VACC,6300010,CDM,510,RC,,,outpatient,,,975,731.25,,780,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,392.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,392.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,731.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,392.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,392.34,780,
EXCIS BENIGN LESION-HEAD FT GEN-3.1-4.0,400046,CDM,360,RC,11424,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
EXCIS BENIGN LESION-TRUNK EXTEM >4.0,400050,CDM,360,RC,11406,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
EXCIS BENIGN LESION-TRUNK EXTEM 3.1-4.0,400052,CDM,360,RC,11404,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
INTERPERIODIC SCREENING 0-12 YRS,6300015,CDM,510,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
EXCIS MAL LESION-FACE 3.1-4.0,400061,CDM,360,RC,11644,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
EXCIS MAL LESION-HEAD FEET GEN 2.1-3.0,400066,CDM,360,RC,11623,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
EXCIS MAL LESION-HEAD FEET GEN 3.1-4.0,400067,CDM,360,RC,11624,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
EXCIS MAL LESION-TRUNK EXTEM >4.0,400069,CDM,360,RC,11606,HCPCS,outpatient,,,2179,1634.25,,1743.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1198.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,876.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1743.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,876.83,2843.72,
SKIN GRAFT FREE TRUCK 20SQ CM OR<,6200289,CDM,360,RC,15200,HCPCS,outpatient,,,2180,1635,,1744,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,877.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1199,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,877.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,877.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1635,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,877.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,877.23,3449.93,
PLATE 4 HOLE DISTAL CLAVICLE RIGHT MM,890287,CDM,278,RC,C1713,HCPCS,both,,,2181.34,1636.01,,1745.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,877.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1199.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1090.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1090.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1090.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1090.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1090.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1090.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1745.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1636.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1636.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1636.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1636.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,877.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,877.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1526.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1636.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1745.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1745.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,877.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1745.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,1745.07,
EXC BACK TUMOR LESS THAN 5 CM,6200432,CDM,510,RC,21932,HCPCS,outpatient,,,2191,1643.25,,1752.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,881.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3757.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3757.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3757.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1205.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,881.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,881.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1643.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,881.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,881.66,3817.9,
GREENFIELD VCF FILTER SYSTEM,400085,CDM,361,RC,75940,HCPCS,outpatient,,,2198,1648.5,,1758.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,884.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1099,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1099,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1099,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1208.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,884.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,884.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1648.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,884.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,884.48,1758.4,
INSERT TRIDENT X3 0 POLYETHYLENE,890167,CDM,278,RC,C1776,HCPCS,both,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1760,
IMPL DELIVERY SYS DISTAL BICEP BC,890261,CDM,278,RC,C1713,HCPCS,both,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,1760,
BASEPLATE TRIATHLON PRIMARY TIBIAL,890264,CDM,278,RC,C1713,HCPCS,both,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,1760,
FEMORAL HEAD BILOX DELTA CERAMIC V40,890274,CDM,278,RC,C1776,HCPCS,both,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1760,
INSERT TRIDENT X3 10 POLYETHYLENE,890277,CDM,278,RC,C1776,HCPCS,both,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1760,
FEMORAL HEAD BIOLOX DELTA CERAMIC V40 36,890278,CDM,278,RC,C1776,HCPCS,both,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1760,
HIV RAPID TEST,6300038,CDM,300,RC,86703,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,37.27,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6.85,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,17.82,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.71,100,,,fee schedule,100% UHC fee schedule for outpatient setting,13.71,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,21.93,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20.56,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,6.85,37.27,
CT ABD AND PELVIS WITH/WO CONTRAST,4300004,CDM,352,RC,74178TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT ABDOMEN WITH,4300005,CDM,352,RC,74160TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT ABDOMEN WITH & WO,4300006,CDM,352,RC,74170TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT BRAIN WITH,4300008,CDM,351,RC,70460TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT CHEST WITH,4300011,CDM,352,RC,71260TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT CHEST WITH & WO,4300012,CDM,352,RC,71270TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT C-SPINE W & WO,4300014,CDM,352,RC,72127TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT CTA CHEST W/,4300017,CDM,352,RC,71275TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT CTA PELVIS W/WO & IMAGE PROCESSING,4300018,CDM,352,RC,72191TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT LOWER EXT W & WO RT,4300021,CDM,352,RC,73702TCRT,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT LOWER EXT WITH RT,4300022,CDM,352,RC,73701RTTC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CTA LOWER EXTREMITY,4300024,CDM,352,RC,73706TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT L-SPINE WITH,4300025,CDM,352,RC,72132TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT L-SPINE WITH & WO,4300026,CDM,352,RC,72133TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT NECK WITH,4300028,CDM,351,RC,70491TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT NECK WITH & WO,4300029,CDM,351,RC,70492TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT ORBITS WITH,4300031,CDM,351,RC,70481TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
HEARING SCREEN,6300060,CDM,510,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
KIDMED NURSE SCREENING,6300061,CDM,510,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
CT ORBITS WITH & WO,4300032,CDM,351,RC,70482TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
VISION SCREENING,6300063,CDM,510,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
WIC 17 PKU LEAD,6300064,CDM,510,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
CT PELVIS WITH,4300034,CDM,352,RC,72193TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT PELVIS WITH & WO,4300035,CDM,352,RC,72194TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT SINUSES WITH,4300037,CDM,351,RC,70487TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT SINUSES WITH & WO,4300038,CDM,351,RC,70488TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT T-SPINE W & WO,4300040,CDM,352,RC,72130TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT T-SPINE WITH,4300041,CDM,352,RC,72129TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
EST LEVEL 3 OV,6300071,CDM,510,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
CT UPPER EXT W & WO RT,4300043,CDM,352,RC,73202RTTC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
EST LEVEL 4 OV,6300073,CDM,510,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
EST LEVEL 5 OV,6300074,CDM,510,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
CT UPPER EXT WITH RT,4300044,CDM,352,RC,73201TCRT,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CTA HEAD,4300048,CDM,352,RC,70496TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CTA NECK,4300049,CDM,352,RC,70498TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CTA UPPER EXTREMITY RT,4300050,CDM,352,RC,73206RTTC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT C-SPINE WITH,4300051,CDM,352,RC,72126TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT LOWER EXT WITH LT,4300061,CDM,352,RC,73701TCLT,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT UPPER EXT W & WO LT,4300064,CDM,352,RC,73202TCLT,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT UPPER EXT WITH LT,4300065,CDM,352,RC,73201TCLT,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CTA UPPER EXTREMITY LT,4300067,CDM,352,RC,73206TCLT,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CTA UPPER EXTREMITY UNILATERAL  W/WO,4300068,CDM,352,RC,73206TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CTA LOWER EXTREMITY UNILATERAL W/WO,4300069,CDM,352,RC,73706TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
CT SINUSES WITH & WO,4310068,CDM,351,RC,70488TC,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1760,
AMPUTATION FOLLOWUP SURGERY,6200570,CDM,360,RC,27886,HCPCS,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2200,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2200,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2200,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2200,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2200,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2200,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2200,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2200,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,885.28,8416.6,
FEMORAL HEAD LFIT ANATOMIC V40 36MM,890168,CDM,278,RC,C1776,HCPCS,both,,,2202.64,1651.98,,1762.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,886.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1211.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1101.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1101.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1101.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1101.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1101.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1101.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1762.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1651.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1651.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1651.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1651.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,886.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,886.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1541.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1651.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1762.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1762.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,886.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1762.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1762.11,
LAPAROSCOPY LYSIS,6200581,CDM,360,RC,58660,HCPCS,outpatient,,,2211,1658.25,,1768.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,889.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1216.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1768.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,889.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,889.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1768.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1658.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1768.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1768.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,889.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1768.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,889.71,8162.33,
ER CLO TX MANDIBLE FX/DISLOC W MANIP,1400032,CDM,450,RC,21451,HCPCS,outpatient,,,2230,1672.5,,1784,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,897.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,897.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,897.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,897.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,897.35,2051.58,
EXC ABDOMINAL TUMOR DEEP 5CM>,6200593,CDM,360,RC,22901,HCPCS,outpatient,,,2231,1673.25,,1784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,897.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1227.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,897.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,897.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1673.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,897.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,897.75,5022.7,
THORASCOPY SURGICAL,6200298,CDM,360,RC,32650,HCPCS,outpatient,,,2241,1680.75,,1792.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,901.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1120.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1120.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1120.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2241,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1232.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2241,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2241,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2241,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,901.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,901.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2241,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2241,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1680.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,901.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2241,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2241,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2241,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1792.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,901.78,2241,
BONE MARROW BIOPSY,1400006,CDM,450,RC,38221,HCPCS,outpatient,,,2260,1695,,1808,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,909.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,507.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,909.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,909.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1695,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,909.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,507.3,2216.25,
AMPUTATION OF FOOT AT ANKLE,6200529,CDM,360,RC,27888,HCPCS,outpatient,,,2275,1706.25,,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1251.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2275,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2275,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,915.46,2275,
AMPUTATION OF FOOT AT ANKLE,6200543,CDM,510,RC,27888,HCPCS,outpatient,,,2275,1706.25,,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1251.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1706.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,915.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2275,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2275,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2275,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,915.46,2275,
ER REMOVAL EMB FB MOUTH COMPLICATED,1400159,CDM,450,RC,40805,HCPCS,outpatient,,,2276,1707,,1820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,632.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,393.99,1820.8,
ER REP LAC TONGUE/FLOOR MOUTH > 2.6CM,1400172,CDM,450,RC,41252,HCPCS,outpatient,,,2276,1707,,1820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,1820.8,
ER REP LIP FULL THICK TO 1/2 HEIGHT,1400174,CDM,450,RC,40652,HCPCS,outpatient,,,2276,1707,,1820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,632.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,393.99,1820.8,
ER REP LIP FULL THICK/>1/2 HIGH-COMPLEX,1400175,CDM,450,RC,40654,HCPCS,outpatient,,,2276,1707,,1820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,2051.58,
ER REP LIP FULL THICKNESS/VERMILLION,1400176,CDM,450,RC,40650,HCPCS,outpatient,,,2276,1707,,1820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,632.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,393.99,1820.8,
ER TRACHEOSTOMY-TRANSTRACHEAL,1400211,CDM,450,RC,31603,HCPCS,outpatient,,,2276,1707,,1820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,2051.58,
NEW PT LEVEL 1 OV,6300103,CDM,521,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
NEW PT LEVEL 2 OV,6300104,CDM,521,RC,,,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
NEW PT LEVEL 3 OV,6300105,CDM,521,RC,,,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
NEW PT LEVEL 4 OV,6300106,CDM,521,RC,,,outpatient,,,175,131.25,,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,70.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,70.42,140,
NEW PT LEVEL 5 OV,6300107,CDM,521,RC,,,outpatient,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.54,180,
ER TRACHEOSTOMY EMERGENCY CRICOTHYROID M,1400503,CDM,450,RC,31605,HCPCS,outpatient,,,2276,1707,,1820.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1536.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,179.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1707,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,287.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1820.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,179.25,1820.8,
SKIN GRAFT FACE AND NECK,6200038,CDM,510,RC,15120,HCPCS,outpatient,,,2279,1709.25,,1823.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,917.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1253.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1823.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2805.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2805.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2805.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,917.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,917.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1823.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1709.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1823.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,917.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4807.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3004.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4507.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1823.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,917.07,4807.8,
EXC SHOULDER TUMOR DEEP 5CM OR GREATER,6200492,CDM,360,RC,23073,HCPCS,outpatient,,,2290,1717.5,,1832,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,921.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1259.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,921.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,921.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1717.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,921.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,921.5,5022.7,
EXC ARM/ELBOW TUMOR DEEP 5 CM OR >,6200404,CDM,360,RC,24073,HCPCS,outpatient,,,2291,1718.25,,1832.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,921.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1260.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1832.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,921.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,921.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1832.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1718.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1832.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1832.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,921.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1832.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,921.9,5022.7,
ER CLO TX FX TALUS WITH MANIPULATION,1400028,CDM,450,RC,28435,HCPCS,outpatient,,,2294,1720.5,,1835.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,923.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,923.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,923.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1835.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1720.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1835.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1835.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,923.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1835.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,326.11,2120.14,
ER CLO TX STENOCLAVICULA DISLOC WO MANIP,1400043,CDM,450,RC,23520,HCPCS,outpatient,,,2296,1722,,1836.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,923.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,923.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,923.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1722,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,923.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,326.11,2120.14,
LAP CHOLECYSTECTOMY,6200354,CDM,510,RC,47562,HCPCS,outpatient,,,2300,1725,,1840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1265,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,925.52,8162.33,
EXCISIONAL DEBRIDEMENT SUBCUT TISSUE & M,1400265,CDM,450,RC,11043,HCPCS,outpatient,,,2304,1728,,1843.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,927.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1555.4,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1843.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,501.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,927.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,927.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1843.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1728,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1843.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1843.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,927.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,858.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,536.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,804.94,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1843.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,501.05,1843.2,
"AMPUTATION LEG AT THIGH,OPEN CIRCULAR",6200050,CDM,360,RC,27592,HCPCS,outpatient,,,2306,1729.5,,1844.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,927.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1153,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1153,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1153,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2306,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1268.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2306,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2306,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2306,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,927.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,927.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2306,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2306,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1729.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,927.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2306,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2306,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2306,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,927.93,2306,
REM TUNNELED CV CATH WO PORT/PUMP,1400248,CDM,761,RC,36589,HCPCS,outpatient,,,2312,1734,,1849.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1271.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,498.94,1849.6,
REMOVAL TUNNELED CV DEVICE W PORT/PUMP,1400249,CDM,761,RC,36590,HCPCS,outpatient,,,2312,1734,,1849.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1271.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1734,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,930.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2061.52,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1849.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,930.35,2198.96,
CHEST TUBE/THORACOSTOMY,1400212,CDM,450,RC,32551,HCPCS,outpatient,,,2318,1738.5,,1854.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1055.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,2198.94,
LIVER BIOPSY,1400240,CDM,761,RC,47000,HCPCS,outpatient,,,2318,1738.5,,1854.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1138.25,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1274.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,932.76,2216.25,
REPLACE PICC WO SUBCU PORT,1400251,CDM,761,RC,36584,HCPCS,outpatient,,,2318,1738.5,,1854.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1274.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,932.76,2198.94,
THORACENTESIS TUBE INSERTION,1400255,CDM,761,RC,32422,HCPCS,outpatient,,,2318,1738.5,,1854.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1274.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,932.76,1854.4,
PLACEMENT TUN CENT VEN CATH >AGE5,1400292,CDM,450,RC,36569,HCPCS,outpatient,,,2318,1738.5,,1854.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1738.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1854.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,2198.94,
RURAL HEALTH OV,6300126,CDM,521,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
FBR: SUBQ COMPLEX,1400165,CDM,450,RC,10121,HCPCS,outpatient,,,2320,1740,,1856,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382.34,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4382.34,
ER ROMOVAL FB UPPER ARM/ELBOW SUBCU,1400178,CDM,450,RC,24200,HCPCS,outpatient,,,2320,1740,,1856,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,786.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,933.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,786.48,2216.25,
LAPAROSCOPY EXCISE LESION,6200356,CDM,510,RC,58662,HCPCS,outpatient,,,2326,1744.5,,1860.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,935.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1279.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,935.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,935.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1860.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1744.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1860.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,935.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1860.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,935.98,8162.33,
MULTI-LINK STENT2.5MMX23,90001934,CDM,270,RC,C1876,HCPCS,outpatient,,,2332,1749,,1865.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,938.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1166,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1166,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1166,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1282.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1865.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,938.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,938.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1865.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1749,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1865.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1865.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,938.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1865.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,938.4,1865.6,
POLYSOMNOGRAM,5600024,CDM,920,RC,95810,HCPCS,outpatient,,,2336,1752,,1868.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1284.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,805.88,1868.8,
PLACE GASTROSTOMY TUBE,6200231,CDM,360,RC,43830,HCPCS,outpatient,,,2336,1752,,1868.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4560.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4560.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4560.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1284.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1752,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,940.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,940.01,4560.41,
S-T AUTOGRAFT TRUNK ARMS LEGS 1ST 100CM,6200294,CDM,360,RC,15100,HCPCS,outpatient,,,2338,1753.5,,1870.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,940.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1285.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,940.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,940.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1753.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,940.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,940.81,3449.93,
THYROID PARTIAL LOBECTOMY UNILATERAL,6200301,CDM,360,RC,60220,HCPCS,outpatient,,,2345,1758.75,,1876,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,943.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1289.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,943.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,943.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1758.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,943.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1876,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,943.63,7703.27,
THYROID LOBECTOMY UNILATERAL W/ORWO IST,6200300,CDM,360,RC,60210,HCPCS,outpatient,,,2349,1761.75,,1879.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,945.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1291.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1879.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,945.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,945.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1879.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1761.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1879.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1879.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,945.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1879.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,945.24,7703.27,
INSERT TRIDENT X3 POLYETHYLENE,890254,CDM,278,RC,C1776,HCPCS,both,,,2362.8,1772.1,,1890.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,950.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1299.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1181.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1181.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1181.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1181.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1181.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1181.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1890.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1772.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1772.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1772.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1772.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,950.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,950.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1653.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1772.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1890.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1890.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,950.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1890.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1890.24,
MRI TEMPOROMANDIBULAR JTS,4200042,CDM,610,RC,70336TC,HCPCS,outpatient,,,2371,1778.25,,1896.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,954.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1185.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1185.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1185.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1896.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1778.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1778.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1778.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1778.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,954.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,954.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1896.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1778.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1896.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1896.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,954.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1896.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,954.09,1896.8,
"AMP METACARPAL W/FINGER/THUMB, W/WO INTE",6200617,CDM,360,RC,26910,HCPCS,outpatient,,,2374,1780.5,,1899.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,955.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4765.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4765.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4765.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1305.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1899.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,955.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,955.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1899.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1780.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1899.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1899.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,955.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1899.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,955.3,4765.11,
ABD HYSTERTY W/WO REMOV OF TUBES/OVARY(S,6900259,CDM,982,RC,58150,HCPCS,outpatient,,,2383,1787.25,,,,,,other,Not separately reimbursable for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1429.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,647.11,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1599.92,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,999.95,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1399.93,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,647.11,1599.92,
FORM SKIN PEDICLE FLAP,6200173,CDM,360,RC,15570,HCPCS,outpatient,,,2393,1794.75,,1914.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,962.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1316.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,962.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,962.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,962.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,962.94,3449.93,
GARDASIL VACC .5 ML,6300143,CDM,972,RC,90649,HCPCS,outpatient,,,0.01,0.01,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,0.01,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,0.01,0.01,
SHELL TRIDENT II CLUSTERHOLE ACETABULAR,890166,CDM,278,RC,C1776,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
SHELL TRIDENT II CLUSTERHOLE ACETABULAR,890276,CDM,278,RC,C1776,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
LIFESTENT BM SELF EXP,5800102,CDM,278,RC,C1876,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,965.76,1920,
STENT EVEROLIMUS ELUTING CORONARY,5890027,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
CORONARY STENT EVEROLIMUS ELUTING XIENCE,5890036,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
CORONARY STENT EVEROLIMUS ELUTING SYSTEM,5890037,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS ELUTING C,5890043,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS ELUTING C,5890050,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS ELUTING C,5890051,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS ELUTING C,5890056,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS ELUTING C,5890057,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS ELUTING C,5890058,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT SYS XIENCE SIERRA ELUTING CORONARY,5890062,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT SYS XIENCE SIERRA CORONARY XIENCE,5890063,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT SYS XIENCE SIERRA ELUTING CORONARY,5890064,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA CORONARY ELUTING,5890072,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS 12 MM,5890074,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
HBV,6300163,CDM,972,RC,90744,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,47.84,160,,,fee schedule,160% CMS Medicare fee schedule for physician setting,29.9,100,,,fee schedule,100% CMS Medicare fee schedule for physician setting,41.86,140,,,fee schedule,140% CMS Medicare fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,29.9,47.84,
HOSPITAL PHYSICAL,6300164,CDM,637,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
PREV MED AGE 40-64,6300167,CDM,972,RC,99396,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,73.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,73.03,73.03,
THUMB SPLINT,6300168,CDM,637,RC,L3999,HCPCS,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
STENT XIENCE SIERRA EVEROLIMUS,5890075,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT EVEROLIMUS ELUTING CORONARY 2.75MM,5890076,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT EVEROLIMUS ELUTING CORONARY,5890077,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA EVEROLIMUS ELUTING,5890078,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SIERRA 1550250-12 DRUG ELUT,5890081,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
MEASLES MUMPS RUBELLA VARICELLA,6300176,CDM,510,RC,90710,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,256,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,160,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,240,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,160,256,
STENT SYS EVEROLIMUS ELUTING CORONARY,5890090,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT SYS EVEROLIMUS ELUTING CORONARY,5890091,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT EVEROLIMUS ELUTING CORONARY XIENCE,5890094,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT EVEROLIMUS CORONARY XIENCE SIERRA,5890105,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SKYPOINT EVERLIMUS ELUTING,5890136,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SKYPOINT ELUTING CORONARY,5890137,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT EVEROLIMUS ELUTING CORONARY XIENCE,5890146,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SKYPOINT 1804300-18,5890148,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SKYPOINT ELUTING CORONARY,5890152,CDM,270,RC,C1874,HCPCS,outpatient,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SKYPOINT EVERLIMUS ELUTING,5890153,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
STENT XIENCE SKYPOINT EVERLIMUS ELUTING,5890154,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
LAP CHOLECYSTECTOMY W/CHOLANGIOGRAPHY,6200373,CDM,360,RC,47563,HCPCS,outpatient,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,965.76,8162.33,
AMP LOWER LEG AT KNEE,6200591,CDM,360,RC,27598,HCPCS,outpatient,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2400,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2400,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2400,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,965.76,2400,
ELUTING CORONARY STENT,90006536,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
CORONARY STENT SYSTEM EVEROLIMUS,90006600,CDM,278,RC,C1874,HCPCS,both,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,1920,
NM STRESS AND REST STUDY-BOTH,4400056,CDM,341,RC,78452,HCPCS,outpatient,,,2409,1806.75,,1927.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,969.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1324.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1927.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,969.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,969.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1927.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1806.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1927.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2089.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,969.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1961.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1839.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1927.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,938.17,2089.5,
RAPID COVID ANTIGEN - SCHOOL BASED HEALT,6300196,CDM,510,RC,87426,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,17.66,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,45.93,130,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,45.37,100,,,fee schedule,100% UHC fee schedule for outpatient setting,45.23,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,56.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,52.99,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.66,56.52,
AMPUTATION STUMP REVISION,6200502,CDM,360,RC,27596,HCPCS,outpatient,,,2419,1814.25,,1935.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,973.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1209.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1209.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1209.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2419,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1330.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1935.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2419,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2419,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2419,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,973.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,973.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2419,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1935.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2419,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1814.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1935.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1935.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,973.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2419,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2419,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2419,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1935.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,973.41,2419,
INCISION & DRAINAGE OF ABSCESS; SIMPLE,6510060,CDM,510,RC,10060,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,375.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,375.41,
"DEBRIDEMENT, SUB TISSUE WOUND",6511042,CDM,510,RC,11042,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,990.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,321.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,551.37,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,344.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,516.9,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,321.76,990.21,
DEBRIDMENT ADDITIONAL 20 SQ CM WOUND CAR,6511045,CDM,761,RC,11045,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,0.01,0.01,
REMOVAL OF BENIGN LESION; 2-4 LESIONS,6511056,CDM,761,RC,11056,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,266.88,
CHEMICAL CAUTERIZATION WOUND CARE,6517250,CDM,761,RC,17250,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,266.88,
APPLICATION  OF  A UNA BOOT,6529580,CDM,510,RC,29580,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,379.9,
"WOUND CLINID APPL OF MULLAY COMP L,A,F",6529581,CDM,510,RC,29581,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,226.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,226.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,226.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,226.3,
DEBRIDMENT OPEN WOUND,6597597,CDM,761,RC,97597,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,129.41,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,129.41,266.87,
DEBRIDMENT ADDITIONAL,6597598,CDM,761,RC,97598,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,161.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,161.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,161.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,161.85,161.85,
REMOVAL OF DEVIATALIZED TISSUE,6597602,CDM,761,RC,97602,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,302.24,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,302.24,
NEW PT EXPAND PROBLEM FOCUS WOUND CARE,6599202,CDM,510,RC,99202,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,134.33,
NEW PT DETAILED WOUND CARE,6599203,CDM,510,RC,99203,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,154.55,
NEW PT MOD COMP WOUND CARE,6599204,CDM,510,RC,99204,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
NEW PT COMP HIGH COMPLEX WOUND CARE,6599205,CDM,510,RC,99205,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
EST PT MINIMAL NO MD WOUND CARE,6599211,CDM,761,RC,99211,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,134.33,134.33,
EST OV WOUND  PROBLEM FOCUSED,6599212,CDM,510,RC,99212,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,134.33,
EST EXPANDED PROBLEM WOUND CLINIC,6599213,CDM,510,RC,99213,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,154.55,
EST OV WOUND CARE,6599214,CDM,510,RC,99214,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
EST COMP HIGH COMPLEXITY WOUND CARE,6599215,CDM,510,RC,99215,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
EXPLORATION OF CHEST,6200166,CDM,360,RC,32035,HCPCS,outpatient,,,2435,1826.25,,1948,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,979.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2435,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1339.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2435,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2435,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2435,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,979.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,979.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2435,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1948,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2435,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1826.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1948,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,979.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2435,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2435,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2435,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1948,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,979.84,2435,
EXC NECK LESION SC 5CM>,6200558,CDM,360,RC,21554,HCPCS,outpatient,,,2436,1827,,1948.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,980.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1339.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,980.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,980.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1827,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,980.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1948.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,980.25,5022.7,
AMPUTATION FOOT;TRANSMETATARSAL,6200054,CDM,360,RC,28805,HCPCS,outpatient,,,2441,1830.75,,1952.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,982.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4340.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4340.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4340.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1342.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,982.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,982.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1830.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,982.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,982.26,4399.33,
CT LOWER EXT W & WO LT,4300060,CDM,352,RC,73702TCLT,HCPCS,outpatient,,,2445,1833.75,,1956,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,983.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,1956,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,983.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,983.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1956,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1833.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1956,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1956,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,983.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1956,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,1956,
"Laparoscopy, w/ total hysterectomy, uter",6100723,CDM,981,RC,58570,HCPCS,outpatient,,,2448,1836,,,,,,other,Not separately reimbursable for physician setting,602.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,795.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1468.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,795.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,795.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,795.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,602.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,602.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,795.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,795.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,602.07,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1273.06,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,795.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1113.92,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,602.07,1468.8,
EXCISION LESION OF MUSCLE DEEP 5CM>,6200479,CDM,360,RC,21933,HCPCS,outpatient,,,2453,1839.75,,1962.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,987.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1349.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,987.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,987.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1839.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,987.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,987.09,5022.7,
OVARIAN CYSTECTOMY,6200222,CDM,360,RC,58925,HCPCS,outpatient,,,2455,1841.25,,1964,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,987.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1350.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,987.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,987.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1841.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,987.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,987.89,6850.42,
REPAIR OF BLADDER WOUND,6200540,CDM,360,RC,51860,HCPCS,outpatient,,,2470,1852.5,,1976,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,993.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3788.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3788.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3788.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7904.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1358.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7380.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7380.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7380.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,993.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,993.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7904.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7904.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1852.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,993.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12647.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7904.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,993.93,12647.55,
MRA HEAD W/O CONTRAST,4200003,CDM,615,RC,70544TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRA NECK W/O CONTRAST,4200006,CDM,615,RC,70547TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI ABDOMEN W/O CONTRAST,4200009,CDM,612,RC,74181TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI CER/SPINE W/O CONTRAST,4200018,CDM,612,RC,72141TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI CHEST W/O CONTRACT,4200022,CDM,611,RC,71550TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI LOWER EXT JOINT W/O CONTRAST RT,4200023,CDM,610,RC,73721TCRT,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI LOWER EXTREMITY NOT JOINT W/O CON RT,4200026,CDM,612,RC,73718TCRT,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI LUMB/SPINE W/O CONTRAST,4200027,CDM,612,RC,72148TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI ORBIT/FACE/NECK W/O CONTRAST,4200035,CDM,611,RC,70540TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI PELVIS W/O CONTRAST,4200037,CDM,612,RC,72195TC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI UPPER EXT JOINT W/O CONTRAST RT,4200045,CDM,610,RC,73221TCRT,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI UPPER EXTREMITY NOT JOINT W/O RT,4200048,CDM,612,RC,73218RTTC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI LOWER EXT JOINT W/O CONTRAST LT,4200054,CDM,610,RC,73721TCLT,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI LOWER EXTREMITY NOT JOINT W/O CON LT,4200057,CDM,610,RC,7371826,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI UPPER EXT JOINT W/O CONTRAST LT,4200058,CDM,610,RC,73221TCLT,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
MRI UPPER EXTREMITY NOT JOINT W/O LT,4200065,CDM,612,RC,73218LTTC,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,1976.8,
REPAIR INCISIONAL HERNIA; REDUCIBLE,6200364,CDM,510,RC,49560,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1359.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,5430.82,
REPAIR INCISIONAL HERNIA; REDUCIBLE,6200634,CDM,510,RC,49591,HCPCS,outpatient,,,2471,1853.25,,1976.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1235.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1359.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1853.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,994.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1976.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,994.33,5234.76,
INJECTAFER 750MG/NSS 250 ML,3204611,CDM,636,RC,J1439,HCPCS,both,,,2481.84,1861.38,,1985.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,998.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1365.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1985.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1861.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1861.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1861.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1861.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,998.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,998.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1985.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1861.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1985.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1985.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,998.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1.68,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1985.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.12,1985.47,
"INJ(S) SINGLE TNDN SHEATH/LIGMT, APONEUR",6820550,CDM,510,RC,20550,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
"INJECTION, SINGLE TENDON ORIGIN/INSERTIO",6820551,CDM,510,RC,20551,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
"INJCTN, SNGL/MULTPL TRGR PNTS 1-2MUSCLES",6820552,CDM,510,RC,20552,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
"INJCTN, SNGL/MULTPL TRGR PNTS 3+ MUSCLES",6820553,CDM,510,RC,20553,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
ARTHROCENTESIS ASPRTN/INJ SMALL JNT/BRSA,6820600,CDM,510,RC,20600,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
ARTHROCENTESIS ASPRTN/INJ JNT/BRSA WO US,6820605,CDM,510,RC,20605,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
ARTHROCENTESIS ASPIRTN/INJ MJR JNT/BURSA,6820610,CDM,510,RC,20610,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
ASPIRATION INJ OF GANGLION CYST,6820612,CDM,510,RC,20612,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,429.76,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,234.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,401.82,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,251.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,376.71,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,234.5,429.76,
ASPIRATION AND INJ FOR TX OF BONE CYST,6820615,CDM,510,RC,20615,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,336.95,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,336.95,959.13,
CLOSED TX CLAVICULAR FX WO MANIPULATION,6823500,CDM,510,RC,23500,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLOSED TX SCAPULAR FX WO MANIPULATION,6823570,CDM,510,RC,23570,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLOSED TX PROXIMAL HUMERAL FX WO MANIPUL,6823600,CDM,510,RC,23600,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX HUMERAL TUBER FX WO/MANIP,6823620,CDM,510,RC,23620,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX HUMERAL SHAFT FX WO MANIPULATIO,6824500,CDM,510,RC,24500,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX HUMERAL FX W OR WO/MANIPULATION,6824530,CDM,510,RC,24530,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLOSED TX RADIAL SHFT FX WO MANIPULATION,6825500,CDM,510,RC,25500,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,652.23,
OPEN TX RADIAL SHAFT FX; INTERNAL FIXATI,6825515,CDM,510,RC,25515,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,7183.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7183.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7183.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6110.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,5704.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5704.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5704.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,6110.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,6110.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,9776.04,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6110.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,5704.98,9776.04,
CLOSED TX RADIAL/ULNAR SHFT FX WO MANIPU,6825560,CDM,510,RC,25560,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,652.23,
CLSED DSTL RDL FX/EPIPHYSAL SEP WO/MANIP,6825600,CDM,510,RC,25600,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,652.23,
CLOSED TX METACARPAL FX; SINGLE WO MANIP,6826600,CDM,510,RC,26600,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX METACARPL FX W/MANIP EACH BONE,6826605,CDM,510,RC,26605,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,652.23,
CLSED TX PHALANGEAL FX WO MANIP EACH,6826720,CDM,510,RC,26720,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSD TX DSTL PHALGL FX WO MANIPULATION,6826750,CDM,510,RC,26750,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLOSED TX PATELLA FX WO MANIPULATION,6827520,CDM,510,RC,27520,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
"CLSED TX TIB FX, PROXIMAL WO MANIPULATIO",6827530,CDM,510,RC,27530,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLOSED TX TIBIAL SHAFT FX W/O MANIPULATI,6827750,CDM,510,RC,27750,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX MEDIAL MALLEOUS FX W/O MANIPULA,6827760,CDM,510,RC,27760,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX PROXIMAL FIBU SHAFT FX WO MANIP,6827780,CDM,510,RC,27780,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX DISTAL FIBULAR FX WO MANIPULATI,6827786,CDM,510,RC,27786,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX DISTAL FIB FX W/MANIPULATION,6827788,CDM,510,RC,27788,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,652.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,652.23,
CLOSED TX BIMALLEOLAR ANKLE FX WO MANIPU,6827808,CDM,510,RC,27808,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TX WGHT BRNG DIST FIB W/O MANIPULA,6827824,CDM,510,RC,27824,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLOSED TX CALCANEAL FX WO MANIPULATION,6828400,CDM,510,RC,28400,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLOSED TX METATARSAL FX WO MANIPULATION,6828470,CDM,510,RC,28470,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
CLSED TXFX GRT TOE PHLNX/PHLNGS WO MANI,6828490,CDM,510,RC,28490,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
"CLOSED TX FX, PHALANX WO MANIPULATION",6828510,CDM,510,RC,28510,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,326.11,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,178.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,305.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,191.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,286.82,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,178.54,326.11,
"APPLICATION OF CAST, SHOULDER TO HAND",6829065,CDM,510,RC,29065,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,354.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,206.91,354.56,
"APPLICATION OF CAST, ELBOW TO FINGER SH",6829075,CDM,510,RC,29075,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,354.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,206.91,354.56,
APP LONG ARM SPLINT SHOULDER TO HAND,6829105,CDM,510,RC,29105,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,379.9,
APPLICATION SHORT ARM SPLINT; STATIC,6829125,CDM,510,RC,29125,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,290.49,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,100.14,290.49,
"APPLICATION OF FINGER SPLINT, STATIC",6829130,CDM,510,RC,29130,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,178.23,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,100.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,171.6,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,107.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,160.87,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,100.14,178.23,
"APPLICATION OF FINGER SPLINT, DYNAMIC",6829131,CDM,510,RC,29131,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,84.95,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,53.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,79.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,49.57,84.95,
APPLICATION LONG LEG CAST,6829345,CDM,510,RC,29345,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,354.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,206.91,354.56,
APPLICATION OF SHORT LEG SPLINT,6829515,CDM,510,RC,29515,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,379.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,379.9,
UNLISTED PROCEDURE; CASTING OR STRAPPING,6829799,CDM,510,RC,29799,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,204.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,215.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,125.71,215.42,
NEW PT EXPAND PROBLEM FOCUSED,6899202,CDM,510,RC,99202,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,134.33,
NEW PT DETAILED,6899203,CDM,510,RC,99203,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,154.55,
NEW PT MOD COMP,6899204,CDM,510,RC,99204,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
NEW PT COMP HIGH COMPLEX,6899205,CDM,510,RC,99205,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
EST PT NURSE VISIT,6899211,CDM,761,RC,99211,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,134.33,134.33,
EST OV PROBLEM FOCUSED,6899212,CDM,510,RC,99212,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,33,134.33,
EST EXPANDED PROBLEM,6899213,CDM,510,RC,99213,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,154.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,38,154.55,
EST OV EXPANDED,6899214,CDM,510,RC,99214,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
EST COMP HIGH COMPLEXITY,6899215,CDM,510,RC,99215,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,224.87,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,57,224.87,
US GUIDED NEEDLE PLAC BREAST BX,4000185,CDM,360,RC,19083,HCPCS,outpatient,,,2486,1864.5,,1988.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1000.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,829.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1367.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1988.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1000.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1988.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1864.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1988.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1988.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,1988.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,829.93,2216.25,
PR US CORE BX BREAST ABRAHAM,4110017,CDM,972,RC,19083,HCPCS,outpatient,,,2486,1864.5,,,,,,other,Not separately reimbursable for physician setting,439.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1491.6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,150.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,150.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,150.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,439.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,439.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,150.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,150.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,439.52,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,240.5,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,150.31,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,210.43,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,150.31,1491.6,
LAP VENT/ABD HERNIA REPAIR,6200201,CDM,360,RC,49652,HCPCS,outpatient,,,2495,1871.25,,1996,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1003.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1372.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1003.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1003.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1871.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1003.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1996,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1003.99,7974.21,
STENT W/ DELIVERY SYSTEM COATED,5800184,CDM,278,RC,C1874,HCPCS,both,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1750,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2000,
STENT VISI-PRO BALLOON PERIPHERAL,5890140,CDM,278,RC,C1876,HCPCS,both,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1750,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
STENT VISI-PRO BALLOON PERIPHERAL,5890141,CDM,278,RC,C1876,HCPCS,both,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1750,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
STENT MULTILINK CORONARY,90001577,CDM,278,RC,C1876,HCPCS,both,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1750,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
STENT CORONARY EVEROLIMUS SYSTEM,90006834,CDM,278,RC,C1874,HCPCS,both,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1750,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2000,
FEMORAL HEAD BIOLOX DELTA CERAMIC V40,890253,CDM,278,RC,C1776,HCPCS,both,,,2522.08,1891.56,,2017.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1014.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1387.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1261.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1261.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1261.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1261.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1261.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1261.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2017.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1891.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1891.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1891.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1891.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1014.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1014.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1765.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1891.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2017.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2017.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1014.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2017.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2017.66,
EXC TUMOR SOFT TIS THIGH/KNEE SUB 5CM >,6200616,CDM,360,RC,27339,HCPCS,outpatient,,,2536,1902,,2028.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1020.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1394.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2028.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1020.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1020.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2028.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1902,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2028.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2028.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2028.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1020.49,5022.7,
ER UNLISTED PROCEDURE INTESTINE,1400215,CDM,450,RC,44799,HCPCS,outpatient,,,2544,1908,,2035.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1023.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1717.12,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2035.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,711.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1023.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1023.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2035.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1908,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2035.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2035.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1023.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1220.05,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,762.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1143.79,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2035.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,711.98,2035.2,
POLYSOMNOGRAM SPLIT NIGHT,5200101,CDM,920,RC,95811,HCPCS,outpatient,,,2550,1912.5,,2040,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1402.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,805.88,2040,
POLYSOMNOGRAM W/CPAP,5600025,CDM,920,RC,95811,HCPCS,outpatient,,,2550,1912.5,,2040,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1360.5,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1402.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,805.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1912.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1026.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1380.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,863.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1294.64,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2040,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,805.88,2040,
EXCISION OF BOWEL POUCH,6200427,CDM,510,RC,44800,HCPCS,outpatient,,,2561,1920.75,,2048.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1030.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3395.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3395.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3395.63,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2561,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1408.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2048.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2561,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2561,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2561,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1030.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1030.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2561,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2048.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2561,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1920.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2048.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1030.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2561,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2561,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2561,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2048.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1030.55,3395.63,
CT CTA ABD W/WO & IMAGE PROCESSING,4300016,CDM,352,RC,74175TC,HCPCS,outpatient,,,2565,1923.75,,2052,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1032.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1282.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1282.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,2052,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1923.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1923.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1923.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1923.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1032.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1032.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2052,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1923.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2052,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1032.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2052,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,2052,
PLATE 8 HOLE RIGHT OLECRANON,890204,CDM,278,RC,C1713,HCPCS,both,,,2570.4,1927.8,,2056.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1034.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1413.72,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1285.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1285.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1285.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1285.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1285.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1285.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2056.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1927.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1927.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1927.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1927.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1034.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1799.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1927.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2056.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2056.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1034.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2056.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,2056.32,
REPAIR OF A VENTRAL HERNIA,6200272,CDM,360,RC,49565,HCPCS,outpatient,,,2575,1931.25,,2060,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1036.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1416.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2060,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1036.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1036.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2060,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1931.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2060,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2060,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1036.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2060,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1036.18,5430.82,
LAPAROTOMY EXPLORATORY,6200390,CDM,360,RC,49000,HCPCS,outpatient,,,2585,1938.75,,2068,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1040.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3460.91,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3460.91,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3460.91,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2585,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1421.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2068,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2585,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2585,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2585,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1040.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1040.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2585,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2068,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2585,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1938.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2068,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2068,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1040.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2585,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2585,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2585,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2068,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1040.2,3460.91,
KNEEALIGN2 SINGLE USE (133631),890237,CDM,278,RC,20985,HCPCS,both,,,2590,1942.5,,2072,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1042.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1424.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2072,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1942.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1942.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1942.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1942.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1042.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1042.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1813,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1942.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2072,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2072,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1042.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2072,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.35,2072,
TRIATHLON X3 TIBIAL BEARING INSERT - CR,890265,CDM,278,RC,C1776,HCPCS,both,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2080,
EXCISION LESION 3.1CM TO 4.0CM,6100711,CDM,360,RC,11624,HCPCS,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2843.72,
EXC FACE LESION SCALP < 2CM,6900020,CDM,982,RC,21011,HCPCS,outpatient,,,2610,1957.5,,,,,,other,Not separately reimbursable for physician setting,210.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,249.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1566,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,249.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,249.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,249.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,210.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,210.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,249.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,249.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,210.38,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,398.45,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,249.03,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,348.64,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,210.38,1566,
EXC LESION FACE 2CM OR GREATER,6900021,CDM,982,RC,21012,HCPCS,outpatient,,,2610,1957.5,,,,,,other,Not separately reimbursable for physician setting,227.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,329.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1566,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,329.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,329.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,329.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,227.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,227.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,329.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,329.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,227.75,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,527.46,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,329.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,461.52,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,227.75,1566,
REMOVAL OF OMENTUM,6200250,CDM,360,RC,49255,HCPCS,outpatient,,,2638,1978.5,,2110.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1061.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2638,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1450.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2638,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2638,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2638,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1061.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1061.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2638,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2638,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1978.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1061.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2638,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2638,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2638,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1061.53,3093.15,
STENT PROTEGE' GPS PHERIPHERAL SELF EXPA,5890053,CDM,278,RC,C1876,HCPCS,both,,,2658.34,1993.76,,2126.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1069.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1462.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1329.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2126.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1993.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1993.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1993.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1993.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1069.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1069.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1860.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1993.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2126.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2126.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1069.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2126.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1069.72,2126.67,
NM SINGLE STUDY (STRESS OR REST),4400055,CDM,341,RC,78452,HCPCS,outpatient,,,2659,1994.25,,2127.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1069.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1462.45,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1069.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1069.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1994.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2089.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1069.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1961.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1839.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,938.17,2127.2,
NM EJECTION FRACTION,4400011,CDM,341,RC,78454,HCPCS,outpatient,,,2660,1995,,2128,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1070.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,687.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,687.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,687.31,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1463,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1070.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1070.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1995,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2089.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1070.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1961.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1839.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,687.31,2128,
REMICADE POWDER FOR INJ 100MG,3203706,CDM,636,RC,J1745,HCPCS,both,,,2671.84,2003.88,,2137.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1075.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1469.51,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1335.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2137.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2003.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2003.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2003.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2003.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1075.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1075.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2137.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2003.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2137.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2137.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1075.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.22,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,48.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2137.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.64,2137.47,
DEBRIDEMENT ABDOMINAL WALL,6200563,CDM,360,RC,11005,HCPCS,outpatient,,,2673,2004.75,,2138.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1075.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1336.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1336.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1336.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2673,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1470.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2673,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2673,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2673,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1075.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1075.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2673,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2673,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2004.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1075.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2673,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2673,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2673,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1075.62,2673,
GASTOSTOMY TUBE PLACEMENT PERCUT,1400219,CDM,761,RC,49440,HCPCS,outpatient,,,2678,2008.5,,2142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1472.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1077.63,2573.96,
INSERTION OF DUO TUBE,1400230,CDM,761,RC,49441,HCPCS,outpatient,,,2678,2008.5,,2142.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1725.5,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1472.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1502.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2008.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1077.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2573.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1608.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1077.63,2573.96,
DALVANCE 500MG,3202231,CDM,636,RC,J0875,HCPCS,both,,,2682,2011.5,,2145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1079.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1475.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1341,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2011.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1079.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1079.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2011.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1079.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,22.81,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.21,2145.6,
STENT XIENCE SKYPOINT 1804300-15,5890147,CDM,278,RC,C1874,HCPCS,both,,,2700,2025,,2160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1485,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1890,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2160,
STENT XIENCE SKYPOINT ELUTING CORONARY,5890151,CDM,278,RC,C1874,HCPCS,both,,,2700,2025,,2160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1485,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1890,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2160,
STENT EVERLIMUS CORONARY SKYPOINT XIENCE,5890155,CDM,278,RC,C1874,HCPCS,both,,,2700,2025,,2160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1485,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1890,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2160,
STENT EVERLIMUS CORONARY SKYPOINT ELUTIN,5890157,CDM,278,RC,C1874,HCPCS,both,,,2700,2025,,2160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1485,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1890,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2025,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1086.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2160,
REPAIR OF ABDOMINAL WALL,6200273,CDM,360,RC,49900,HCPCS,outpatient,,,2715,2036.25,,2172,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1092.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1357.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1357.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1357.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2715,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1493.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2715,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2715,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1092.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1092.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2715,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2715,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2036.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1092.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2715,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2715,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2715,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1092.52,2715,
MRI THOR/SPINE W/O CONTRAST,4200044,CDM,612,RC,72146TC,HCPCS,outpatient,,,2721,2040.75,,2176.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1094.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1360.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2040.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2040.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2040.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2040.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1094.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1094.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2040.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1094.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2176.8,
AMPUTATION LEG AT THIGH THRU FEMUR,6200049,CDM,360,RC,27590,HCPCS,outpatient,,,2728,2046,,2182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1097.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1364,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1364,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1364,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2728,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2728,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2728,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2728,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1097.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1097.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2728,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2728,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1097.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2728,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2728,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2728,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1097.75,2728,
I&D PILONIDAL CYST,1400098,CDM,450,RC,10080,HCPCS,outpatient,,,2736,2052,,2188.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1100.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1845.77,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1100.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2052,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1100.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,559.72,2188.8,
HYSTRCTMY UTERI <250G;REMOV TUBE/OVARY,6100705,CDM,972,RC,58571,HCPCS,outpatient,,,2748,2061,,,,,,other,Not separately reimbursable for physician setting,660.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,892.89,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1648.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,892.89,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,892.89,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,892.89,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,660.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,660.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,892.89,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,892.89,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,660.7,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1428.62,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,892.89,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1250.05,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,660.7,1648.8,
UNLISTED LAP HERNIA REPAIR,6200311,CDM,360,RC,49659,HCPCS,outpatient,,,2800,2100,,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1540,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1126.72,7703.27,
NAIL TROCH. 11 X 180 X 125,890272,CDM,278,RC,C1769,HCPCS,both,,,2809.88,2107.41,,2247.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1130.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1545.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2247.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2107.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2107.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2107.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2107.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1130.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1130.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1966.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2107.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2247.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2247.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1130.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2247.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1130.7,2247.9,
PLATE BUTTON TIGHTROPE KNOTLESS DIS CLAV,890289,CDM,278,RC,C1713,HCPCS,both,,,2816,2112,,2252.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1133.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1548.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1408,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1408,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1408,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1408,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1408,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1408,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2112,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2112,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2112,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2112,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1133.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1133.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2112,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1133.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,2252.8,
WEDGE BIOPSY OF LIVER,6200318,CDM,360,RC,47100,HCPCS,outpatient,,,2823,2117.25,,2258.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1135.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5246.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5246.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5246.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2823,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1552.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2823,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2823,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2823,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1135.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1135.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2823,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2823,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2117.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1135.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2823,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2823,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2823,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2258.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1135.98,5246.21,
CT ABD AND PELVIS WITH CONTRAST,4300003,CDM,352,RC,74177TC,HCPCS,outpatient,,,2830,2122.5,,2264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1138.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1415,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1415,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1415,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650,100,,,case rate,100% CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,575,100,,,case rate,100% Coventry CT case rate for outpatient setting,2264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2122.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2122.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2122.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2122.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1138.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1138.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2122.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1138.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,575,2264,
LAP SURG REPAIR INCISIONAL HERNIAREDUCI,6200200,CDM,360,RC,49654,HCPCS,outpatient,,,2840,2130,,2272,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1142.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1562,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1142.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1142.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2130,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1142.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1142.82,7974.21,
FLEBOGAMMA 5% 20GM/400ML,3202775,CDM,636,RC,J1572,HCPCS,both,,,2859.6,2144.7,,2287.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1150.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1572.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1429.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2287.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2144.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2144.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2144.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2144.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1150.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2287.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2144.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2287.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2287.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1150.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,56.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,84.18,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2287.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,56.12,2287.68,
REPAIR DIAPHRAGM LACERATION,6200267,CDM,360,RC,39501,HCPCS,outpatient,,,2860,2145,,2288,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1150.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2860,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1573,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2860,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2860,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2860,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1150.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2860,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2860,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2145,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1150.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2860,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2860,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2860,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1150.86,2860,
CIRCUMCISION;NOT NEWBORN,400014,CDM,360,RC,54161,HCPCS,outpatient,,,2861,2145.75,,2288.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1573.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1151.27,3748.83,
CIRCUMSISION WIHT REGONAL DORSAL,400015,CDM,361,RC,54150,HCPCS,outpatient,,,2861,2145.75,,2288.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3748.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1573.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1151.27,3748.83,
VASECTOMY,400150,CDM,361,RC,55250,HCPCS,outpatient,,,2861,2145.75,,2288.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1573.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2145.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1151.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1151.27,4427.19,
EXC INTESTINE LESION SINGLE ENTEROTOMY,6200458,CDM,360,RC,44110,HCPCS,outpatient,,,2866,2149.5,,2292.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1153.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1433,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1433,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1433,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2866,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1576.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2866,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2866,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2866,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1153.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1153.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2866,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2866,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2149.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1153.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2866,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2866,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2866,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2292.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1153.28,2866,
"REMOVE FOREIGN BODY, ABDOMEN",6200258,CDM,360,RC,49402,HCPCS,outpatient,,,2876,2157,,2300.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1157.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4264.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1581.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1157.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1157.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2157,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1157.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1157.3,5234.76,
EXCIS BENIGN LESION-FACE >4.0,400036,CDM,360,RC,11446,HCPCS,outpatient,,,2880,2160,,2304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1584,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1158.91,3817.9,
EXCIS BENIGN LESION-HEAD FT GEN >4.0,400042,CDM,360,RC,11426,HCPCS,outpatient,,,2880,2160,,2304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1584,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1158.91,3817.9,
EXCIS MAL LESION-FACE >4.0,400057,CDM,360,RC,11646,HCPCS,outpatient,,,2880,2160,,2304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1584,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1158.91,3817.9,
EXCIS MAL LESION-HEAD FEET GEN >4.0,400063,CDM,360,RC,11626,HCPCS,outpatient,,,2880,2160,,2304,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1584,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2160,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1158.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1158.91,3817.9,
ANGIO BRACHIAL  RETROGRADE,5800017,CDM,320,RC,75658,HCPCS,outpatient,,,2900,2175,,2320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1595,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1166.96,2320,
ANGIO LT & RT VERT  CERVICAL,5800019,CDM,320,RC,36225,HCPCS,outpatient,,,2900,2175,,2320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1595,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1166.96,7072.35,
ANGIO BIL CAROTID CERVICAL,5800020,CDM,320,RC,36224,HCPCS,outpatient,,,2900,2175,,2320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11566.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,11566.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,11566.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1595,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7121.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1166.96,11566.45,
ANGIO CAROTID CEREBRAL UNILATERAL,5800199,CDM,320,RC,36222,HCPCS,outpatient,,,2900,2175,,2320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1595,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1166.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1166.96,7072.35,
REPAIR BOWEL OPENING,6200264,CDM,360,RC,44620,HCPCS,outpatient,,,2918,2188.5,,2334.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1174.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5519.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5519.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5519.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2918,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1604.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2918,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2918,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2918,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1174.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1174.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2918,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2918,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1174.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2918,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2918,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2918,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1174.2,5519.61,
INCISION OF GALLBLADDER EXP DRAIN REMOV,6200190,CDM,360,RC,47480,HCPCS,outpatient,,,2922,2191.5,,2337.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1175.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1461,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1461,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1461,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2922,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1607.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2922,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2922,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2922,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1175.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1175.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2922,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2922,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2191.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1175.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2922,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2922,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2922,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1175.81,2922,
Laparoscopic uterosacral nerve ablation,6100471,CDM,521,RC,58578,HCPCS,outpatient,,,2930,2197.5,,2344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1179.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1611.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1179.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1179.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2197.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1179.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1179.03,7703.27,
APPENDECTOMY-OPEN RUPTURED W ABSCESS,6200061,CDM,360,RC,44960,HCPCS,outpatient,,,2943,2207.25,,2354.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1184.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2943,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1618.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2943,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2943,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2943,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1184.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1184.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2943,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2943,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2207.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1184.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2943,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2943,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2943,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1184.26,3093.15,
EXPLORATION RETROPERITONEAL W/WO BIOPSY,6100683,CDM,969,RC,49010,HCPCS,outpatient,,,2974,2230.5,,,,,,other,Not separately reimbursable for physician setting,593.14,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,915.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1784.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,915.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,915.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,915.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,593.14,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,593.14,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,915.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,915.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,593.14,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1464.42,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,915.26,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1281.36,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,593.14,1784.4,
RITUXAN 500 MG INJ,3206306,CDM,636,RC,J9312,HCPCS,both,,,2975,2231.25,,2380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1197.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1636.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2231.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2231.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2231.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2231.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,80.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1197.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2231.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1197.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.3,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,80.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,120.28,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.19,2380,
MRI THOR/SPINE W CONTRAST,4000218,CDM,612,RC,72157TC,HCPCS,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2400,
STENT NON/COAT/NONCOVER/W DELIVERY,5800180,CDM,278,RC,C1876,HCPCS,both,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,2400,
LAPARO HERNIA REPAIR INI,6100104,CDM,510,RC,49650,HCPCS,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,8162.33,
REREPAIR ING HERNIA RED,6200280,CDM,360,RC,49520,HCPCS,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,5430.82,
LAP HERNIA REPAIR,6200355,CDM,510,RC,49650,HCPCS,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,8162.33,
LAP VERTICAL SLEEVE GASTRECTOMY,6200482,CDM,360,RC,43775,HCPCS,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10397.55,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,10397.55,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,10397.55,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3000,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3000,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,10397.55,
REREPAIR ING HERNIA BLOC,6200587,CDM,360,RC,49521,HCPCS,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,5430.82,
P-MASTECTOMY W/LN REMOVAL,6200566,CDM,360,RC,19302,HCPCS,outpatient,,,3012,2259,,2409.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1212.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8018.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8018.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8018.01,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1656.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1212.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1212.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1212.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8783.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1212.03,8783.64,
BIOPSY/REMOVAL  LYMPH NODE,400006,CDM,360,RC,38500,HCPCS,outpatient,,,3020,2265,,2416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1215.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4059.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1661,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1215.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1215.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2265,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1215.25,5080.87,
HAND CASTING,1400285,CDM,450,RC,26775,HCPCS,outpatient,,,3021,2265.75,,2416.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1215.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,206.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1215.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1215.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2265.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,354.56,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,221.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,332.4,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.91,2719.14,
PACER REMOVAL OF GENERATOR ONLY,5800115,CDM,480,RC,33233,HCPCS,outpatient,,,3054,2290.5,,2443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7540.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1679.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7540.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7540.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12064.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7540.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11310.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1228.93,12064.13,
PACER REMOVAL OF LEAD DUAL ONLY,5800116,CDM,480,RC,33235,HCPCS,outpatient,,,3054,2290.5,,2443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1679.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4952.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4642.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1228.93,4952.49,
PACER REMOVAL OF LEAD SINGLE ONLY,5800117,CDM,480,RC,33234,HCPCS,outpatient,,,3054,2290.5,,2443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1679.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4952.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4642.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1228.93,4952.49,
REMOVAL OF AICD GENERATOR SINGLE OR DUAL,5800157,CDM,480,RC,33241,HCPCS,outpatient,,,3054,2290.5,,2443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1679.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4952.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4642.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1228.93,4952.49,
REPOSITION OF LEADS ALL TYPES,5800164,CDM,480,RC,33215,HCPCS,outpatient,,,3054,2290.5,,2443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1679.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1228.93,4402.75,
REVOVAL-ICD PACING LEAD SINGLE OR DUAL,5800167,CDM,480,RC,33244,HCPCS,outpatient,,,3054,2290.5,,2443.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4168.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1679.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2290.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1228.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4952.49,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3095.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4642.96,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1228.93,4952.49,
THYROID COMPLETE REMOVAL,6200299,CDM,360,RC,60240,HCPCS,outpatient,,,3067,2300.25,,2453.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1234.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1686.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1234.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1234.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2300.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1234.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1234.16,7703.27,
TVC REPLAC SAME SITE,5800191,CDM,480,RC,36581,HCPCS,outpatient,,,3070,2302.5,,2456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1235.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1688.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1235.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1235.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2302.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1235.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1235.37,4402.75,
EXCIS BREAST LESION (WO RADIOLOGY),400053,CDM,360,RC,19120,HCPCS,outpatient,,,3084,2313,,2467.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1696.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1241,5080.87,
EXCIS BREAST LESION ADDITIONAL W RADIOL,400054,CDM,360,RC,19126,HCPCS,outpatient,,,3084,2313,,2467.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1542,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1696.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1241,3684.92,
EXCIS BREAST LESION W RADIOLOGY MARKER,400055,CDM,360,RC,19125,HCPCS,outpatient,,,3084,2313,,2467.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3684.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1696.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2965.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2313,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1241,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.87,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3175.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1241,5080.87,
PARTIAL REMOVAL OF THYROID,6200586,CDM,360,RC,60225,HCPCS,outpatient,,,3088,2316,,2470.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1242.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1698.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1242.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1242.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2316,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1242.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1242.61,7703.27,
LAP INCISIONAL HERNIA REPAIR RECURRENT,6200420,CDM,360,RC,49656,HCPCS,outpatient,,,3091,2318.25,,2472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1243.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1545.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1700.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2472.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1243.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1243.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2472.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2318.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2472.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2472.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1243.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2472.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1243.82,7974.21,
EXP LAPAROTOMY,6200370,CDM,360,RC,44180,HCPCS,outpatient,,,3093,2319.75,,2474.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1244.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1701.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2474.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1244.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1244.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2474.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2319.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2474.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2474.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1244.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2474.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1244.62,8162.33,
LEEP,400098,CDM,360,RC,57522,HCPCS,outpatient,,,3100,2325,,2480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1247.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1705,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1247.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1247.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2325,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1247.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1247.44,5080.81,
ZOLEDRONIC ACID 5MG/100ML,3202267,CDM,636,RC,J3489,HCPCS,both,,,3105,2328.75,,2484,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1249.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1707.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1552.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2484,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2328.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2328.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2328.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2328.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1249.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1249.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2484,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2328.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2484,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2484,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1249.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2484,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1249.45,2484,
BX LYMPH-CER/ING/AX,4001137,CDM,360,RC,38505,HCPCS,outpatient,,,3111,2333.25,,2488.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1711.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,679.41,2488.8,
BX SALIVARY GLAND,4200082,CDM,360,RC,42400,HCPCS,outpatient,,,3111,2333.25,,2488.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,679.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1711.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,559.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2333.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1251.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,959.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,599.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,899.19,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,559.72,2488.8,
AMPUTATION BELOW THE KNEE,6200374,CDM,360,RC,27880,HCPCS,outpatient,,,3120,2340,,2496,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1255.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3642.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3642.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3642.92,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3120,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1716,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3120,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3120,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3120,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1255.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1255.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3120,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3120,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2340,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1255.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3120,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3120,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3120,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1255.49,3642.92,
RPR VENTRAL HERNIA INITIAL,6200284,CDM,360,RC,49561,HCPCS,outpatient,,,3132,2349,,2505.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1566,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1722.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1260.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1260.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2349,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1260.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1260.32,5430.82,
EXPLORATION BEHIND ABDOMINAL INCISION,6200165,CDM,360,RC,49010,HCPCS,outpatient,,,3144,2358,,2515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1265.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3460.91,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3460.91,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3460.91,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3144,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1729.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3144,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3144,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3144,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1265.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1265.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3144,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3144,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2358,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1265.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3144,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3144,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3144,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2515.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1265.15,3460.91,
REDUCE BOWEL OBSTRUCTION,6200242,CDM,360,RC,44050,HCPCS,outpatient,,,3150,2362.5,,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3150,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1732.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3150,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3150,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3150,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3150,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3150,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3150,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3150,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3150,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1267.56,8416.6,
LAP REPR W/MESH INCARCERATED HERNIA,6200606,CDM,360,RC,49653,HCPCS,outpatient,,,3150,2362.5,,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7974.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1575,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1732.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2362.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1267.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1267.56,7974.21,
"Excision, benign lesion 3.1 - 4 cm",6100578,CDM,521,RC,11424,HCPCS,outpatient,,,3159,2369.25,,2527.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1271.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1737.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2527.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1271.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1271.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2527.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2369.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2527.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1271.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2527.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1271.18,2843.72,
SUPRACERVICAL ABD HYSTERECTOMY ASSISTING,6200295,CDM,360,RC,58180,HCPCS,outpatient,,,3163,2372.25,,2530.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1272.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3163,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1739.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2530.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3163,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3163,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3163,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1272.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1272.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3163,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2530.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3163,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2372.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2530.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2530.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1272.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3163,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3163,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3163,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2530.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1272.79,3218.62,
CYSTOSCOPY,400026,CDM,361,RC,52204,HCPCS,outpatient,,,3174,2380.5,,2539.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1277.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3522.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3522.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3522.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1745.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1277.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1277.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2380.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1277.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1277.22,3522.88,
INCISION HERNIA W/OBST W/O GANGRENE,6200590,CDM,360,RC,49566,HCPCS,outpatient,,,3178,2383.5,,2542.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1278.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1589,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1747.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2542.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1278.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1278.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2542.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2542.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2542.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1278.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2542.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1278.83,5430.82,
GAMUNEX-C 10GM/100ML,3207194,CDM,636,RC,J1561,HCPCS,both,,,3200,2400,,2560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1760,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.81,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,49.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,73.89,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.26,2560,
IVC FILTER,5800095,CDM,270,RC,37191,HCPCS,outpatient,,,3200,2400,,2560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9865.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9865.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9865.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1760,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2400,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1287.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1287.68,9865.8,
AMP THIGH THRU FEMUR FITTING TECH CAST,6200611,CDM,360,RC,27591,HCPCS,outpatient,,,3220,2415,,2576,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1295.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1610,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1610,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1610,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3220,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1771,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3220,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3220,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3220,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1295.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1295.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3220,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3220,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2415,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1295.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3220,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3220,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3220,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1295.73,3220,
PRIVIGEN INTRAVENOUS SOLUTION 10% (20 GM,3203135,CDM,636,RC,J1459JG,HCPCS,both,,,3240,2430,,2592,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1303.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1782,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2430,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2430,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2430,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2430,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1303.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1303.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2430,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1303.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1303.78,2592,
TREATMENT OF INCOMPLETE ABORTION SURGICA,6100453,CDM,521,RC,59812,HCPCS,outpatient,,,3264,2448,,2611.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1313.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3313.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3313.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3313.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1795.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1313.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2448,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1313.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2611.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1313.43,4178.79,
PICC LINE PLACEMENT TECH,7000038,CDM,761,RC,36569,HCPCS,outpatient,,,3282,2461.5,,2625.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1320.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1805.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1283.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1320.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1320.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2461.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1320.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2198.94,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1374.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2625.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1283.24,2625.6,
"ENTEROTOMY SM INTEST EXP,BX, FB REMOVAL",6200422,CDM,360,RC,44020,HCPCS,outpatient,,,3285,2463.75,,2628,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1321.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1642.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1642.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1642.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3285,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1806.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3285,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3285,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3285,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1321.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1321.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3285,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3285,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2463.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1321.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3285,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3285,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3285,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2628,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1321.88,3285,
REPAIR BLOOD VESSEL DIRECT; NECK,6200263,CDM,360,RC,35201,HCPCS,outpatient,,,3293,2469.75,,2634.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1325.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4419.64,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.64,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.64,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1811.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1325.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2469.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1325.1,7596.28,
STENT CORONARY XIENCE,90001566,CDM,278,RC,C1874,HCPCS,both,,,3300,2475,,2640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1815,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2310,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2640,
COLOSTOMY WITH MULTIPLE BIOPSIES,6200082,CDM,360,RC,44322,HCPCS,outpatient,,,3301,2475.75,,2640.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1328.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1650.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3301,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1815.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3301,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3301,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3301,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1328.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1328.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3301,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3301,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2475.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1328.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3301,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3301,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3301,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1328.32,3301,
MIACALCIN 400 I.U./2 ML,3201369,CDM,636,RC,J0630,HCPCS,both,,,3306,2479.5,,2644.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1330.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1296.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1818.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2644.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2479.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2479.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2479.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2479.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1296.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1296.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1296.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1330.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1330.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1296.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2644.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1296.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2479.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2644.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2644.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1330.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2074.17,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1296.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1944.53,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2644.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1296.33,2644.8,
EXCISION OF STOMACH LESION,6200453,CDM,360,RC,43610,HCPCS,outpatient,,,3310,2482.5,,2648,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1331.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6574.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6574.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6574.46,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3310,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2648,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3310,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3310,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3310,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1331.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1331.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3310,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2648,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3310,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2482.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2648,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2648,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1331.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3310,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3310,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3310,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2648,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1331.94,6574.46,
"INCISION OF LARGE BOWEL EXP,BX,FB REMOVA",6200410,CDM,360,RC,44025,HCPCS,outpatient,,,3323,2492.25,,2658.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1337.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1661.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1661.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1661.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3323,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1827.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2658.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3323,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3323,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3323,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1337.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1337.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3323,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2658.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3323,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2492.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2658.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2658.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1337.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3323,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3323,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3323,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2658.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1337.18,3323,
INSERT TRIATHLON X3 TIBIAL BEARING,890243,CDM,278,RC,C1776,HCPCS,both,,,3328.16,2496.12,,2662.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1339.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1664.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1830.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1664.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2662.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2496.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2496.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2496.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2496.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1339.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1339.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2329.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2496.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2662.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2662.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1339.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2662.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2662.53,
TOTAL ABDOMINAL HYSTERECTOMY ASSISTING,6200397,CDM,360,RC,58150,HCPCS,outpatient,,,3338,2503.5,,2670.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1343.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3338,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1835.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3338,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3338,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3338,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1343.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1343.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3338,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3338,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1343.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3338,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3338,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3338,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1343.21,3338,
LAP W VAGINAL HYSTER UTERUS </=250 G,6100694,CDM,969,RC,58550,HCPCS,outpatient,,,3340,2505,,,,,,other,Not separately reimbursable for physician setting,577.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,871.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2004,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,871.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,871.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,871.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,577.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,577.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,871.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,871.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,577.55,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1393.82,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,871.14,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1219.6,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,577.55,2004,
PARTIAL RELEASE OF LUNG,6200224,CDM,360,RC,32225,HCPCS,outpatient,,,3359,2519.25,,2687.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1351.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1679.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1679.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1679.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3359,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1847.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2519.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2519.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2519.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2519.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3359,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3359,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3359,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1351.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1351.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3359,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3359,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2519.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1351.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3359,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3359,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3359,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1351.66,3359,
MASTECTOMY SIMPLE COMPLETE,6200416,CDM,360,RC,19303,HCPCS,outpatient,,,3366,2524.5,,2692.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1354.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5969.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5969.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5969.16,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1851.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2692.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2524.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2524.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2524.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2524.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5125.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1354.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1354.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2692.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2524.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2692.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2692.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1354.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8783.64,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5489.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2692.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1354.48,8783.64,
PARTIAL THYROID LOBECTOMY SUBTOTAL INCL,6200524,CDM,360,RC,60212,HCPCS,outpatient,,,3379,2534.25,,2703.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1359.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7671.21,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1858.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2534.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2534.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2534.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2534.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1359.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1359.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2534.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1359.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1359.71,7703.27,
REPAIR BOWEL OPENING,6200265,CDM,360,RC,44625,HCPCS,outpatient,,,3422,2566.5,,2737.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1377.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1711,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1711,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1711,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3422,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1882.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2566.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2566.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2566.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2566.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3422,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3422,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3422,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1377.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1377.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3422,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3422,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2566.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1377.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3422,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3422,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3422,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2737.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1377.01,3422,
REDUCTION RADIAL HEAD DISLOCATION,1400291,CDM,450,RC,24605,HCPCS,outpatient,,,3441,2580.75,,2752.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1384.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2580.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2580.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2580.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2580.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1384.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1384.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2580.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1384.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,2752.8,
SHOULDER DISLOCATION:WITH  ANESTHESIA,1400270,CDM,450,RC,23655,HCPCS,outpatient,,,3444,2583,,2755.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1385.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2719.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2755.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2583,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2583,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2583,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2583,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1237.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1385.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2755.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2583,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2755.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2755.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2120.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1325.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2755.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,2755.2,
MRI BRAIN W/O CONTRAST,4200017,CDM,610,RC,70551TC,HCPCS,outpatient,,,3471,2603.25,,2776.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1396.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1735.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1735.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1735.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1735.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2603.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2603.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2603.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2603.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1396.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1396.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2603.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1396.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2776.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2776.8,
I&D FELON (COMPLICATED FINGER ABSCESS),1400262,CDM,450,RC,26011,HCPCS,outpatient,,,3477,2607.75,,2781.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1399.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2212.96,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2781.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2607.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2607.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2607.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2607.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1399.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1399.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2781.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2607.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2781.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2781.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1399.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2781.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,2781.6,
MRA ABD W CONTRAST,4200001,CDM,618,RC,C8900,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRA HEAD W/CONTRAST,4200002,CDM,615,RC,70545TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRA HEAD W/WO CONTRAST,4200004,CDM,615,RC,70546TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRA NECK W/CONTRAST,4200005,CDM,615,RC,70548TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRA NECK W/W/O CONTRAST,4200007,CDM,615,RC,70549TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI ABD W/WO CONTRAST,4200008,CDM,612,RC,74183TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI ABDOMEN WITH CONTRAST,4200010,CDM,612,RC,74182TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI LOWER EXT JOINT W&W/0 CONTRAST RT,4200011,CDM,610,RC,73723TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI LOWER EXT JOINT W/CONTRAST RT,4200012,CDM,610,RC,73722RTTC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI UPPER EXT JOINT W&W/O CONTRAST RT,4200013,CDM,610,RC,73223TCRT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI UPPER EXT JOINT W/CONTRAST RT,4200014,CDM,612,RC,73222TCRT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI BRAIN W/AND/WO CONTRAST,4200015,CDM,610,RC,70553TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI BRAIN W/CONTRAST,4200016,CDM,610,RC,70552TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI CER/SPINE W/WO/CONTRAST,4200019,CDM,612,RC,72156TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI CHEST W&W/O CONTRAST,4200020,CDM,610,RC,71552TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI CHEST W/CONTRAST,4200021,CDM,610,RC,71551TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
DO NOT USE,4200024,CDM,610,RC,73721RT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI LOWER EXTR NOT JOINT W/CONTRAST RT,4200025,CDM,610,RC,73719TCRT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI LUMB/SPINE W/WO/CONTRAST,4200028,CDM,612,RC,72158TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI ORBIT FACE AND NECK W/CONTRAST,4200033,CDM,610,RC,70542TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI PELVIS W CONTRAST,4200036,CDM,610,RC,72196TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI PELVIS W/WO CONTRAST,4200038,CDM,612,RC,72197TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI SPINAL CANAL CERVICAL W/CONTRAST,4200039,CDM,610,RC,72142TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
LIDOCAINE VISCOUS UD,6900188,CDM,637,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
MRI SPINAL CANAL LUMBAR W/CONTRAST,4200040,CDM,610,RC,72149TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI SPINAL CANAL THORACIC W/CONTRAST,4200041,CDM,610,RC,72147TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI THOR/SPINE W/WO/CONTRAST,4200043,CDM,612,RC,72157TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI UPPER EXT NOT JOINT W/WO/CONTRAST RT,4200046,CDM,610,RC,73220RTTC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI UPPER EXT NOT JOINT W CONTRAST RT,4200047,CDM,610,RC,73219RTTC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI CERVICAL SPINE W/CONTRAST,4200049,CDM,610,RC,72142TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI LOWER EXT JOINT W&W/0 CONTRAST LT,4200050,CDM,610,RC,73723TCLT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI LOWER EXT JOINT W/CONTRAST LT,4200051,CDM,610,RC,73722LTTC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI UPPER EXT JOINT W/CONTRAST LT,4200053,CDM,612,RC,73222LTTC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
DO NOT USE,4200055,CDM,610,RC,73721LT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
GERILANTA  UD,6900201,CDM,982,RC,,,outpatient,,,5,3.75,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,3,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,3,3,
MRI LOWER EXTR NOT JOINT W/CONTRAST LT,4200056,CDM,610,RC,73719TCLT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
IBUPROFEN 200 TABS,6900203,CDM,982,RC,,,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,1.8,1.8,
IBUPROFEN SUSP PER DOSE,6900204,CDM,982,RC,,,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,1.8,1.8,
TYLENOL SUSP PER DOSE,6900205,CDM,982,RC,,,outpatient,,,3,2.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,1.8,1.8,
INSTA GLUCOSE,6900206,CDM,982,RC,,,outpatient,,,10,7.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,6,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,6,6,
DO NOT USE,4200060,CDM,610,RC,74183,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1196.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1196.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1196.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRI ABD W/CONTRAST,4200061,CDM,610,RC,74182TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
DO NOT USE,4200062,CDM,610,RC,73720,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1196.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1196.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1196.05,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRI UPPER EXT NOT JOINT W CONTRAST LT,4200066,CDM,610,RC,73219LTTC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRI UPPER EXT NOT JOINT W/WO/CONTRAST LT,4200067,CDM,610,RC,73220LTTC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRA LOWER EXTREMITY WITH CONTRAST,4200071,CDM,618,RC,C8912,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRA PELVIS W CONTRAST,4200072,CDM,618,RC,C8918,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,951.62,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRA ABD W/O CONTRAST,4200073,CDM,615,RC,C8901,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.4,2784.8,
MRA ABD W & W/O CONTRAST,4200074,CDM,615,RC,C8902,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRA CHEST W/O CONTRAST,4200075,CDM,615,RC,C8910,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.4,2784.8,
MRA LOWER EXT W CONTRAST,4200076,CDM,615,RC,C8912TC,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MRA LOWER EXT W/O CONTRAST,4200077,CDM,615,RC,C8913,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.4,2784.8,
MRA LOWER EXT W & W/O CONTRAST,4200078,CDM,615,RC,C8914,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRA PELVIS W/O CONTRAST,4200079,CDM,615,RC,C8919,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,895.7,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.21,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,345.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,215.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,323.55,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.4,2784.8,
MRA PELVIS W&W/O CONTRAST,4200080,CDM,615,RC,C8920,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1298.55,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,317.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.99,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,544.5,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,340.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,510.48,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.76,2784.8,
MRI UPPER EXT JOINT W&W/O CONTRAST LT,4200081,CDM,614,RC,73223TCRT,HCPCS,outpatient,,,3481,2610.75,,2784.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1740.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2610.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2784.8,
MOBILE CARDIAC OP THER TELEMETRY,5200108,CDM,732,RC,93229,HCPCS,outpatient,,,3495,2621.25,,2796,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1406.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1935.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1935.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1935.06,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1922.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2621.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2621.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2621.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2621.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,125.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1406.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1406.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2621.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1406.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,214.92,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,134.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,201.49,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,125.43,2796,
RESECT THIGH/KNEE TUMOR 5CM OR GREATER,6200551,CDM,510,RC,27364,HCPCS,outpatient,,,3500,2625,,2800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5022.7,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1925,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1408.4,5022.7,
EXCISION OF MESENTERY LESION,6200553,CDM,510,RC,44820,HCPCS,outpatient,,,3500,2625,,2800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1925,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1408.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3500,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3500,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3500,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1408.4,3500,
PR MRI THOR/SPINE W CONTRAST,4010218,CDM,972,RC,7215726,HCPCS,outpatient,,,3503,2627.25,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2101.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,2101.8,2101.8,
"ILEOSTOMY OR JEJUNOSTOMY, NON TUBE",6200186,CDM,360,RC,44310,HCPCS,outpatient,,,3510,2632.5,,2808,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1412.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1755,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1755,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1755,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3510,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1930.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2632.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2632.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2632.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2632.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3510,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3510,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3510,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1412.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1412.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3510,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3510,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2632.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1412.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3510,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3510,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3510,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2808,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1412.42,3510,
REOPENING OF RECENT LAPOROTOMY,6200260,CDM,360,RC,49002,HCPCS,outpatient,,,3527,2645.25,,2821.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1419.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3961.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3961.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3961.41,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3527,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1939.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2821.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2645.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2645.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2645.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2645.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3527,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3527,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3527,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1419.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1419.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3527,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2821.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3527,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2645.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2821.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2821.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1419.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3527,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3527,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3527,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2821.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1419.26,3961.41,
REMOVAL OF THYROID CERVICAL APPROACH,6200476,CDM,360,RC,60271,HCPCS,outpatient,,,3531,2648.25,,2824.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1420.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3120.69,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3120.69,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3120.69,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1942.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2648.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2648.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2648.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2648.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1420.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1420.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2648.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1420.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7891.73,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1420.87,7891.73,
MRI LOW EXT NON JOINT W/WO RT,4200063,CDM,610,RC,73720RTTC,HCPCS,outpatient,,,3546,2659.5,,2836.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2836.8,
MRI LOW EXT NON JOINT W/WO LT,4200064,CDM,610,RC,73720LTTC,HCPCS,outpatient,,,3546,2659.5,,2836.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1773,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2659.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1426.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,2836.8,
SHELL TRIDENT II CLUSTERHOLE ACETABULAR,890252,CDM,278,RC,C1776,HCPCS,both,,,3575.44,2681.58,,2860.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1438.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1787.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1966.49,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1787.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1787.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1787.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1787.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1787.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1787.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2860.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2681.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1438.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1438.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2502.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2681.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2860.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2860.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1438.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2860.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,2860.35,
SUTURE LARGE INTESTINE,6200483,CDM,360,RC,44604,HCPCS,outpatient,,,3578,2683.5,,2862.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1439.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1789,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1789,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1789,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3578,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1967.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2683.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2683.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2683.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2683.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3578,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3578,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3578,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1439.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1439.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3578,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3578,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2683.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1439.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3578,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3578,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3578,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2862.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1439.79,3578,
CATHETER INPACT ADMIRAL PACLITAXEL-COAT,5890139,CDM,278,RC,C2623,HCPCS,both,,,3580,2685,,2864,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1440.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1969,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1790,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2864,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2685,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2685,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2685,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2685,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1440.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2506,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2685,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2864,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2864,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2864,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1440.59,2864,
CHOLECYSTECTOMY OPEN,6200327,CDM,510,RC,47600,HCPCS,outpatient,,,3590,2692.5,,2872,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1444.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1974.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2692.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2692.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2692.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2692.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1444.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1444.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2692.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1444.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3590,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3590,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1444.62,8300.68,
TRIATHLON CRUCIATE RETAINING FEMORAL  #2,890263,CDM,278,RC,C1716,HCPCS,both,,,3600,2700,,2880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1980,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,230.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,230.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,230.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,369.2,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,230.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,346.12,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,230.75,2880,
INSERT NONTUNNEL CENT VENOUS CATH TECHNI,7000046,CDM,761,RC,36556,HCPCS,outpatient,,,3613,2709.75,,2890.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1453.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1987.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2709.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2709.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2709.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2709.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1453.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1453.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2709.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1453.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2890.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1453.87,4402.75,
BRCA 1/2 COMPREHENSIVE ANALYSIS,2801096,CDM,301,RC,81162,HCPCS,outpatient,,,3618,2713.5,,2894.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1824.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,5302.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5302.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5302.34,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,912.44,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,1989.9,55,,,percent of total billed charges,55% of total billed charges for lab procedure in outpatient setting,2372.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2372.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2372.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2372.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2372.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2372.34,130,,,fee schedule,130% Coventry fee schedule for outpatient setting,2894.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1824.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1824.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1824.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1824.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1824.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,1824.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2894.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1824.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2894.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1824.88,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1824.88,100,,,fee schedule,100% LA Medicaid fee schedule for outpatient setting,2919.8,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1824.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2737.32,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2894.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,912.44,5302.34,
THYROID REMOVAL REMAINING THYROID/REPEAT,6200302,CDM,360,RC,60260,HCPCS,outpatient,,,3648,2736,,2918.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1467.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2006.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2736,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2736,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2736,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2736,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1467.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1467.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2736,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1467.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7891.73,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1467.96,7891.73,
CATARACT EXTRACTION W/IOL,266984,CDM,360,RC,66984,HCPCS,outpatient,,,3650,2737.5,,2920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1468.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4421.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4421.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4421.24,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1994.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2007.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2737.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2737.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2737.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2737.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1862.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1862.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1862.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1468.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1468.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1994.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1994.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2737.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1468.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3191.52,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1994.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1468.76,4421.24,
LAPAROSCOPY FUNDOPLASTY,6200485,CDM,360,RC,43280,HCPCS,outpatient,,,3651,2738.25,,2920.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1469.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2008.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2920.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2738.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2738.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2738.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2738.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1469.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1469.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2920.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2738.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2920.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2920.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1469.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13430.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2920.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1469.16,13430.53,
ABD AORTOGRAPHY/BIL RUN-OFF,5800010,CDM,320,RC,75630,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4578.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,4578.66,
AORTAGRAM AP/LAT,5800025,CDM,320,RC,75625,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4578.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,4578.66,
EACH ADDL VESSELL,5800064,CDM,320,RC,75774,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1101.25,2942.4,
EST/ART/UN RUNOFF,5800068,CDM,320,RC,75710,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4578.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,4578.66,
EXT ART BILAT RUNOFF,5800071,CDM,320,RC,75716,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4578.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,4578.66,
IMA  SMA OR CEL ART,5800078,CDM,320,RC,75726,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7632.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7121.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,7632.59,
IVC GRAM,5800097,CDM,320,RC,75825,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4578.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1101.25,4578.66,
PELVIC ART/SEL,5800123,CDM,320,RC,75736,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7632.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7121.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,7632.59,
RENAL VENOGRAM BILATERAL,5800160,CDM,320,RC,75833,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4578.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1101.25,4578.66,
RENAL VENOGRAM UNILATERAL,5800161,CDM,320,RC,75831,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1101.25,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4578.66,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1101.25,4578.66,
RENAL/BILAT/FLUSH,5800162,CDM,320,RC,36252,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6629.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6629.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6629.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,6629.88,
RENAL/UNII/FLUSH/SEL,5800163,CDM,320,RC,36253,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6629.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6629.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6629.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7121.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,7596.28,
THORACIC AORTAGRAM,5800188,CDM,320,RC,75605,HCPCS,outpatient,,,3678,2758.5,,2942.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2103.12,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2022.9,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2758.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7632.59,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1480.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7121.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2942.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1480.03,7632.59,
FREEING OF BOWEL ADHESIONS,6200174,CDM,360,RC,44005,HCPCS,outpatient,,,3689,2766.75,,2951.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1484.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3689,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2028.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2951.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2766.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2766.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2766.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2766.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3689,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3689,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3689,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1484.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1484.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3689,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2951.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3689,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2766.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2951.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2951.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1484.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3689,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3689,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3689,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2951.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1484.45,3689,
INSERT TUNNELED CV DEVICE W PORT IN OR,400090,CDM,361,RC,36561,HCPCS,outpatient,,,3710,2782.5,,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1492.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5147.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2040.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2968,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2782.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2782.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2782.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2782.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1492.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1492.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2968,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2782.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2968,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2968,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1492.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2968,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1492.9,5147.17,
NM STRESS MULTIPLE STUDIES REST & OR STR,4400057,CDM,341,RC,78452,HCPCS,outpatient,,,3711,2783.25,,2968.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1493.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,938.17,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2041.05,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2968.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2783.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2783.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2783.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2783.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1144.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1493.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1493.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2968.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2783.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2968.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2089.5,100,,,fee schedule,100% UHC fee schedule for outpatient setting,1493.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1961.63,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1226.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1839.02,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2968.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,938.17,2968.8,
THORACOSTOMY SURGICAL,6200297,CDM,360,RC,32651,HCPCS,outpatient,,,3722,2791.5,,2977.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1497.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1861,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1861,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1861,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3722,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2047.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2977.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2791.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2791.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2791.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2791.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3722,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3722,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3722,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1497.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1497.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3722,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2977.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3722,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2791.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2977.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2977.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1497.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3722,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3722,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3722,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2977.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1497.73,3722,
THORACENTESIS WITH IMAGING GUID-RAD,4000137,CDM,320,RC,32555,HCPCS,outpatient,,,3729,2796.75,,2983.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1500.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1313.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2050.95,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2983.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2796.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,498.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2983.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2796.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2983.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2983.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,854.99,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,534.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,801.54,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,2983.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,498.94,2983.2,
PR BONE BIOPSY DEEP PERCUTANEOUS,4210070,CDM,972,RC,20225,HCPCS,outpatient,,,3729,2796.75,,,,,,other,Not separately reimbursable for physician setting,395.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,125.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2237.4,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,125.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,125.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,125.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,395.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,395.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,125.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,125.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,395.96,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,201.06,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,125.66,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,175.92,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,125.66,2237.4,
HYSTRCTMY UTERI >250G;REMOV TUBE/OVARY,6100707,CDM,972,RC,58573,HCPCS,outpatient,,,3732,2799,,,,,,other,Not separately reimbursable for physician setting,847.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1199.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2239.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1199.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1199.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1199.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,847.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,847.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1199.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1199.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,847.41,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1918.66,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,1199.16,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1678.82,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,847.41,2239.2,
MYOMECTOMY,6200212,CDM,360,RC,58146,HCPCS,outpatient,,,3765,2823.75,,3012,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1515.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3319.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3319.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3319.26,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3765,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2070.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3012,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2823.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2823.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2823.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2823.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3765,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3765,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3765,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1515.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1515.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3765,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3012,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3765,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2823.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3012,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3012,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1515.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3765,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3765,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3765,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3012,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1515.04,3765,
CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY,6200456,CDM,360,RC,47605,HCPCS,outpatient,,,3781,2835.75,,3024.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1521.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2079.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3024.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2835.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2835.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2835.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2835.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1521.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1521.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3024.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2835.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3024.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3024.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1521.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3781,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3781,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3024.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1521.47,8300.68,
RADICAL RESECTION SHOULDER TUMOR< 5CM,6200241,CDM,360,RC,23077,HCPCS,outpatient,,,3790,2842.5,,3032,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1525.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2084.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3032,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2842.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2842.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2842.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2842.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1525.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1525.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3032,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2842.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3032,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3032,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1525.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3032,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1525.1,3817.9,
DO NOT USE,4000206,CDM,343,RC,70553TC,HCPCS,outpatient,,,3820,2865,,3056,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1537.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1910,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1910,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1910,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2101,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2865,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2865,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2865,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2865,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1537.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1537.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2865,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1537.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1537.17,3056,
MARSUPIALIZATION OF PANCREATIC CYST,6200490,CDM,360,RC,48500,HCPCS,outpatient,,,3865,2898.75,,3092,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1555.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3865,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2125.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3092,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2898.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2898.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2898.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2898.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3865,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3865,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3865,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1555.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1555.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3865,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3092,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3865,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2898.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3092,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3092,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1555.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3865,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3865,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3865,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3092,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1555.28,8416.6,
GAMMA L 10 X 400 X 125*,890053,CDM,278,RC,C1713,HCPCS,both,,,3880,2910,,3104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1561.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2134,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1940,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1940,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1940,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1940,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1940,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1940,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2910,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2910,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2910,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2910,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1561.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1561.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2716,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2910,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1561.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,3104,
MRI ORBIT FACE W/WO CONTRAST,4200034,CDM,612,RC,70543TC,HCPCS,outpatient,,,3881,2910.75,,3104.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1561.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1940.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1940.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1940.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150,100,,,case rate,100% BCBS MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,1050,100,,,case rate,100% Coventry MRI case rate for outpatient setting,3104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2910.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2910.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2910.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2910.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1561.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1561.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2910.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1561.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3104.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1050,3104.8,
SPLENECTOMY TOTAL,6200293,CDM,360,RC,38100,HCPCS,outpatient,,,3895,2921.25,,3116,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1567.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1947.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1947.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1947.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3895,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2142.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2921.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2921.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2921.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2921.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3895,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3895,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3895,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1567.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1567.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3895,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3895,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2921.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1567.35,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3895,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3895,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3895,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1567.35,3895,
DRUG ELUTING CORNARY STENT,5800061,CDM,278,RC,C1874,HCPCS,both,,,3900,2925,,3120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2145,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2730,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3120,
XIENCE V-DRUG ELUTING STENT,5800198,CDM,278,RC,C1874,HCPCS,both,,,3900,2925,,3120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2145,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2730,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2925,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1569.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3120,
PLEURX INSERT CHEST TUBE,5800129,CDM,480,RC,32550,HCPCS,outpatient,,,3912,2934,,3129.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1574.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6231.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6231.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6231.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2151.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2934,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2934,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2934,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2934,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1574.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1574.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2934,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1574.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1574.19,6231.87,
VAGOTOMY & PYLORUS REPAIR,6200314,CDM,360,RC,43640,HCPCS,outpatient,,,3969,2976.75,,3175.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1597.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1984.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1984.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1984.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3969,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2182.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2976.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2976.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2976.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2976.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3969,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3969,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3969,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1597.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1597.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3969,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3969,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2976.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1597.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3969,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3969,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3969,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1597.13,3969,
SALPINO OOPHORECTOMY COMPL PART UNI BIL,6200391,CDM,360,RC,58720,HCPCS,outpatient,,,3976,2982,,3180.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1599.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3976,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2186.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2982,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2982,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2982,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2982,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3976,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3976,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3976,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1599.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3976,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3976,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2982,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1599.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3976,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3976,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3976,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1599.94,3976,
RPR UMBIL HERNIA  REDUC>001,400139,CDM,360,RC,49585,HCPCS,outpatient,,,3986,2989.5,,3188.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1603.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2989.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1603.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1603.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2989.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1603.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1603.97,5430.82,
RPR UMBIL HERN  INCAR/STRANGULATED >5YR,400136,CDM,360,RC,49587,HCPCS,outpatient,,,3987,2990.25,,3189.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.37,5430.82,
SUSPENSION OF TESTIS,400145,CDM,361,RC,54550,HCPCS,outpatient,,,3987,2990.25,,3189.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2192.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2990.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.37,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.37,5430.82,
RPR INIT VENT/INC HERNIA INCARC/STRANG,400130,CDM,360,RC,49561,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
RPR INIT VENT/INC HERNIA REDUCIBLE,400131,CDM,360,RC,49560,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
RPR INITIAL ING HERNIA INCAR/STRANG >5YR,400132,CDM,360,RC,49507,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
RPR INITIAL ING HERNIA  REDUCIBLE >5Y,400133,CDM,360,RC,49505,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
RPR RECURRENT ING HERN INCAR/STRANG ANY,400134,CDM,360,RC,49521,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
RPR RECURRENT ING HERN  REDUCIBLE  ANY,400135,CDM,360,RC,49520,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
RPR UMBIL HERN  INCARC/STRANGULATED <5YR,400137,CDM,360,RC,49582,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
RPR UMBIL HERNIA  REDUC AGE <5 YRS,400138,CDM,360,RC,49580,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5430.82,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,5430.82,
REMOVAL OF CHEST WALL LESION,6200244,CDM,360,RC,21601,HCPCS,outpatient,,,3988,2991,,3190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2843.72,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2193.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2991,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1604.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3190.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1604.77,3817.9,
BASEPLATE TRIATHLON TOTAL UNIV TIBIA,890242,CDM,278,RC,C1713,HCPCS,both,,,3989.92,2992.44,,3191.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1605.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2194.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1994.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1994.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1994.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1994.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1994.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1994.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3191.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2992.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2992.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2992.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2992.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1605.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1605.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2792.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2992.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3191.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3191.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3191.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,3191.94,
HIP STEM SECUR-FIT 127 NECK ANGLE V40,890165,CDM,278,RC,C1776,HCPCS,both,,,4000,3000,,3200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2200,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3200,
HIP STEM SECUR-FIT ADV 127 NECK ANGLE 12,890273,CDM,278,RC,C1776,HCPCS,both,,,4000,3000,,3200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2200,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3200,
HIP STEM SECUR-FIT ADV 132 NECK ANGLE V4,890275,CDM,278,RC,C1776,HCPCS,both,,,4000,3000,,3200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2200,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3200,
STENT W/DEL SYSTEM NOT COATED,5800045,CDM,278,RC,C1876,HCPCS,both,,,4000,3000,,3200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2200,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1609.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1609.6,3200,
EXC ABD TUMOR 5 CM OR LESS,6200426,CDM,510,RC,49203,HCPCS,outpatient,,,4029,3021.75,,3223.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1621.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4029,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2215.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3021.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3021.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3021.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3021.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4029,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4029,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4029,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1621.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1621.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4029,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4029,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3021.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1621.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4029,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4029,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4029,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3223.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1621.27,6043.61,
COLOSTOMY OR SKIN LEVEL CECOSTOMY,6200002,CDM,360,RC,44320,HCPCS,outpatient,,,4039,3029.25,,3231.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1625.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2019.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2019.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2019.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4039,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2221.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3029.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3029.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3029.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3029.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4039,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4039,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4039,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1625.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1625.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4039,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4039,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3029.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1625.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4039,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4039,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4039,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1625.29,4039,
ER REMOVAL FB THIGH/KNEE,1400167,CDM,450,RC,27372,HCPCS,outpatient,,,4123,3092.25,,3298.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1659.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3092.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3092.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3092.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3092.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1659.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1659.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3092.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1659.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,3817.9,
REMOVAL SMALL INTESTINE,6200255,CDM,360,RC,44120,HCPCS,outpatient,,,4131,3098.25,,3304.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1662.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4131,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2272.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3098.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3098.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3098.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3098.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4131,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4131,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4131,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1662.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1662.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4131,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4131,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3098.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1662.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4131,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4131,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4131,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1662.31,8416.6,
GAMMAGARD 10% 20 GM 200ML,3208079,CDM,636,RC,J1569,HCPCS,both,,,4154,3115.5,,3323.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1671.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2284.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2077,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1671.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1671.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3115.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1671.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.46,3323.2,
ENDOMETRIAL ABLATION,400032,CDM,361,RC,58353,HCPCS,outpatient,,,4300,3225,,3440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2365,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1730.32,6850.42,
TUBAL LIGATION  UNI/BILAT,400149,CDM,361,RC,58600,HCPCS,outpatient,,,4300,3225,,3440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5080.81,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2365,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1730.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1730.32,5080.81,
ER DELIVERY PLACENTA,1400057,CDM,450,RC,59414,HCPCS,outpatient,,,4324,3243,,3459.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1739.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2775.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3459.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1739.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1739.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3459.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3459.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3459.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1739.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3459.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4178.79,
LAPAROSCOPY MYOTOMY HELLER,6200491,CDM,360,RC,43279,HCPCS,outpatient,,,4382,3286.5,,3505.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1763.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6037.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6037.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6037.73,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4382,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2410.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4382,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4382,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4382,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1763.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1763.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4382,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4382,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3286.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1763.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4382,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4382,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4382,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1763.32,6037.73,
AMPUTATION OF PHALANX WITH DIRECT CLOSUR,1400267,CDM,450,RC,26951,HCPCS,outpatient,,,4393,3294.75,,3514.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1767.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2965.3,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3514.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2567.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1767.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1767.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3514.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3294.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3514.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3514.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1767.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4399.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2749.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3514.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4399.33,
"Hysteroscopy, surgical; with removal of",6100576,CDM,521,RC,58562,HCPCS,outpatient,,,4407,3305.25,,3525.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1773.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3966.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2423.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1773.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1773.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3305.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1773.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1773.38,4178.79,
BOWEL TO BOWEL FUSION,6200070,CDM,360,RC,44130,HCPCS,outpatient,,,4425,3318.75,,3540,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1780.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2212.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2212.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2212.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4425,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2433.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4425,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4425,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4425,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1780.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1780.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4425,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4425,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3318.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1780.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4425,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4425,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4425,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1780.62,4425,
THYROIDECTOMY CA W LIMITED NECK RESECTIO,6200525,CDM,360,RC,60252,HCPCS,outpatient,,,4434,3325.5,,3547.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1784.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7015.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4605.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1784.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1784.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3325.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1784.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7891.73,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4932.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3547.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1784.24,7891.73,
ER I&D SIMPLE HEMATOMA,1400100,CDM,450,RC,10140,HCPCS,outpatient,,,4446,3334.5,,3556.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1789.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3001.14,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1789.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1789.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3334.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1789.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,3556.8,
ANGIO BIL CAROTID CEREBRAL,5800016,CDM,320,RC,36223,HCPCS,outpatient,,,4500,3375,,3600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2475,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7121.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1810.8,7596.28,
ANGIO CERVICOCEREBRAL,5800018,CDM,320,RC,36221,HCPCS,outpatient,,,4500,3375,,3600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7072.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2475,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4127.58,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1810.8,7072.35,
ER ORAL INSI/DRAIN ABCESS/CYST/HEMATOMA,1400153,CDM,450,RC,41000,HCPCS,outpatient,,,4515,3386.25,,3612,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1816.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3047.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,393.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1816.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1816.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3386.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1816.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,675.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,421.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,632.95,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,393.99,3612,
SUTURE SMALL INTSTNE PERF ULCER; SINGLE,6100697,CDM,969,RC,44602,HCPCS,outpatient,,,4522,3391.5,,,,,,other,Not separately reimbursable for physician setting,858.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1399.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2713.2,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1399.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1399.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1399.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,858.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,858.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1399.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1399.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,858.03,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2239.28,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,1399.55,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1959.37,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,858.03,2713.2,
PARTIAL REMOVAL OF COLON,6200228,CDM,360,RC,44140,HCPCS,outpatient,,,4525,3393.75,,3620,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1820.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8416.6,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4525,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2488.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4525,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4525,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4525,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1820.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1820.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4525,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4525,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3393.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1820.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4525,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4525,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4525,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1820.86,8416.6,
LAP COLECTOMY PARTIAL W REMOVAL ILEUM,6200548,CDM,360,RC,44205,HCPCS,outpatient,,,4528,3396,,3622.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1822.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4528,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2490.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3622.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4528,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4528,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4528,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1822.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1822.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4528,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3622.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4528,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3396,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3622.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3622.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1822.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4528,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4528,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4528,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3622.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1822.07,4528,
FEMORAL TRIATHALON CRUCIATE RETAINING,890241,CDM,278,RC,C1776,HCPCS,both,,,4535.52,3401.64,,3628.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1825.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2494.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2267.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2267.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2267.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2267.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2267.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2267.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3628.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3401.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3401.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3401.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3401.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1825.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1825.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3174.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3401.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3628.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3628.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1825.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3628.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3628.42,
ER DRAINAGE SCROTAL WALL ABCESS,1400066,CDM,450,RC,55100,HCPCS,outpatient,,,4577,3432.75,,3661.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1841.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3089.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3661.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1293.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1841.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1841.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3661.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3432.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3661.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3661.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1841.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2216.25,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1385.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3661.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,3661.6,
REMOVAL OF THYROID,6200500,CDM,360,RC,60270,HCPCS,outpatient,,,4590,3442.5,,3672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1847.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2524.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3442.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3442.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3442.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3442.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1847.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1847.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3442.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1847.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4590,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4590,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4590,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1847.02,4590,
LAPARO NEW URETER/BLADDER,6200580,CDM,360,RC,50947,HCPCS,outpatient,,,4650,3487.5,,3720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1871.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2557.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1871.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1871.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3487.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1871.16,8162.33,
REMOVAL OF GALLBLADDER,6200415,CDM,360,RC,47620,HCPCS,outpatient,,,4662,3496.5,,3729.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1875.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2331,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2331,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2331,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4662,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2564.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4662,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4662,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4662,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1875.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1875.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4662,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4662,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4662,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4662,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4662,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3729.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1875.99,4662,
INSERT NON TUNNELED CV CATH >AGE 5,1400226,CDM,361,RC,36556,HCPCS,outpatient,,,4716,3537,,3772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2593.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1560.65,4402.75,
PLACEMENT NON TUNN CEN VEN CATH <AGE 5,1400228,CDM,450,RC,36555,HCPCS,outpatient,,,4716,3537,,3772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4402.75,
PLCMT NON TUNN CENTRAL VEN CATH >AGE 5,1400229,CDM,450,RC,36556,HCPCS,outpatient,,,4716,3537,,3772.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1560.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3537,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1897.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4402.75,
"LAP, URETERONEAL W CYSTOSCOPY AND STENT",6100696,CDM,969,RC,50947,HCPCS,outpatient,,,4768,3576,,,,,,other,Not separately reimbursable for physician setting,991.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1342.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,2860.8,60,,,percent of total billed charges,60% of billed charges for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,1342.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1342.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1342.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,991.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,991.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,1342.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,1342.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,991.1,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,2148.75,160,,,fee schedule,160% CMS Medicare RBRVS fee schedule for physician setting,1342.97,100,,,fee schedule,100% CMS Medicare RBRVS fee schedule for physician setting,1880.16,140,,,fee schedule,140% CMS Medicare RBRVS fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,991.1,2860.8,
SUTURE SMALL INTESTINE FOR ULCER;SINGLE,6200367,CDM,510,RC,44602,HCPCS,outpatient,,,4781,3585.75,,3824.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1923.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5758.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5758.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5758.84,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2629.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3585.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3585.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3585.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3585.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1923.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1923.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3585.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1923.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4781,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4781,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4781,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3824.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1923.87,5758.84,
APPENDECTOMY  OPEN,400003,CDM,360,RC,44950,HCPCS,outpatient,,,4788,3591,,3830.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1926.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3093.15,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2633.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3830.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3591,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3591,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3591,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3591,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3054.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1926.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1926.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3830.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3591,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3830.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3830.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1926.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5234.76,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,3271.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3830.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1926.69,5234.76,
ICATIBANT 30MG/3ML,3207530,CDM,636,RC,J1744,HCPCS,both,,,4800,3600,,3840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1931.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2640,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,146.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1931.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1931.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3600,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1931.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,234.89,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,146.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,220.21,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.81,3840,
GAMMA 10 X 360 X 125,890290,CDM,278,RC,C1713,HCPCS,both,,,4823.62,3617.72,,3858.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1941.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,869.4,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2652.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2411.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2411.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2411.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2411.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2411.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2411.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3858.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3617.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3617.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3617.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3617.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1941.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1941.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3376.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3617.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3858.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3858.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1941.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3858.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,869.4,3858.9,
LEQVIO 284MG/1.5ML,3207437,CDM,636,RC,J1306,HCPCS,both,,,4875,3656.25,,3900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1961.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2681.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1961.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1961.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3656.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1961.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,12.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18.03,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.02,3900,
CHOLECYSTECTOMY - LAP,400012,CDM,360,RC,47562,HCPCS,outpatient,,,4916,3687,,3932.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1978.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2703.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1978.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1978.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1978.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1978.2,8162.33,
CL PTC THROMBCTMY,5800056,CDM,480,RC,92973,HCPCS,outpatient,,,4938,3703.5,,3950.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1987.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6922.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6922.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6922.85,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2469,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2715.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1987.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1987.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3703.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1987.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3950.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1987.05,6922.85,
CORONARY STENT EVEROLIMUS 2.25MMX12M,90000439,CDM,278,RC,C1874,HCPCS,both,,,4950,3712.5,,3960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2722.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3465,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,3960,
LHC-COR ONLY,5800101,CDM,480,RC,93508,HCPCS,outpatient,,,4958,3718.5,,3966.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2479,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2479,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2479,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2479,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2726.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1995.1,3966.4,
RT HEART ONLY,5800173,CDM,480,RC,93451,HCPCS,outpatient,,,4958,3718.5,,3966.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2726.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3718.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1995.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,3966.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1995.1,8687.74,
SILVERHAWK PERIPHERAL PLAQUE EXCISION SY,5890131,CDM,278,RC,C1714,HCPCS,both,,,4990,3742.5,,3992,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2007.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2744.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2495,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2007.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2007.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3493,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3742.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2007.98,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3992,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2007.98,3992,
I&D PERIRECTAL ABSCESS,1400263,CDM,450,RC,46040,HCPCS,outpatient,,,5081,3810.75,,4064.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2044.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3429.47,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4064.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,933.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2044.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2044.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4064.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3810.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4064.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4064.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2044.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1600.47,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1000.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1500.43,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4064.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4064.8,
ER EXPLORATION PENETRATING WOUND CHEST,1400077,CDM,450,RC,20101,HCPCS,outpatient,,,5111,3833.25,,4088.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4088.8,
ER EXPLORATION PENETRATING WOUND TRUNK,1400080,CDM,450,RC,20102,HCPCS,outpatient,,,5111,3833.25,,4088.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3449.93,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1488.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3833.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2056.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2550.71,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1594.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2391.29,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4088.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4088.8,
THROMB W/PRONTO SURG,5800190,CDM,480,RC,36870,HCPCS,outpatient,,,5154,3865.5,,4123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2073.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2577,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2577,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2577,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2577,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2834.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3865.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3865.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3865.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3865.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2073.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2073.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3865.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2073.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2073.97,4123.2,
COLECTOMY PARTIAL,6200378,CDM,360,RC,44204,HCPCS,outpatient,,,5186,3889.5,,4148.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2086.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6043.61,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5186,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2852.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5186,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5186,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5186,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2086.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2086.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5186,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5186,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3889.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2086.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5186,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5186,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5186,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2086.85,6043.61,
LAP PARAESOPHAGEAL HERNIA W FUNDOPLASTY,6200443,CDM,360,RC,43281,HCPCS,outpatient,,,5233,3924.75,,4186.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2105.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17456.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,17456.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,17456.51,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2878.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3924.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3924.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3924.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3924.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2105.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2105.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3924.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2105.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13430.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2105.76,17456.51,
CROFAB 1GM VIAL,3200198,CDM,636,RC,J0840,HCPCS,both,,,5300,3975,,4240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2132.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2076.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2915,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2076.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2076.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2076.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2132.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2132.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2076.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2076.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3975,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2132.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3322.33,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2076.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3114.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2076.46,4240,
DRAIN ABDOMINIAL ABSCESS,6200089,CDM,360,RC,49020,HCPCS,outpatient,,,5368,4026,,4294.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2160.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2749.86,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.86,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2749.86,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5368,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2952.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4026,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4026,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4026,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4026,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5368,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5368,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5368,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2160.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2160.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5368,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5368,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4026,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5368,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5368,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5368,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2160.08,5368,
REMOVAL OF RECTUM,6200442,CDM,360,RC,45120,HCPCS,outpatient,,,5376,4032,,4300.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2163.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2688,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2688,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2688,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5376,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2956.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5376,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5376,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5376,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2163.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2163.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5376,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5376,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4032,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2163.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5376,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5376,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5376,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4300.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2163.3,5376,
REPAIR BOWEL OPENING,6200266,CDM,360,RC,44626,HCPCS,outpatient,,,5420,4065,,4336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2181.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2710,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2710,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2710,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5420,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2981,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4065,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4065,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4065,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4065,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5420,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5420,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5420,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2181.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2181.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5420,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5420,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4065,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2181.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5420,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5420,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5420,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2181.01,5420,
PARTIAL REMOVAL OF COLON,6200227,CDM,360,RC,44145,HCPCS,outpatient,,,5592,4194,,4473.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2250.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2796,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2796,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2796,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5592,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3075.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4194,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4194,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4194,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4194,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5592,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5592,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5592,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2250.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2250.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5592,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5592,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4194,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5592,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5592,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5592,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2250.22,5592,
PARTIAL REMOVAL OF COLON,6200226,CDM,360,RC,44143,HCPCS,outpatient,,,5609,4206.75,,4487.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2257.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2804.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2804.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2804.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5609,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3084.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4487.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4206.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4206.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4206.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4206.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5609,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5609,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5609,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2257.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2257.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5609,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4487.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5609,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4206.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4487.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4487.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2257.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5609,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5609,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5609,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4487.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2257.06,5609,
LAP HERNIA REPAIR,400092,CDM,360,RC,49650,HCPCS,outpatient,,,5766,4324.5,,4612.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3171.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2320.24,8162.33,
LAP HERNIA REPAIR  RECURRENT INGUINAL,400093,CDM,360,RC,49651,HCPCS,outpatient,,,5766,4324.5,,4612.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3171.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2320.24,8162.33,
LAP TUBAL CAUTERY,400094,CDM,360,RC,58670,HCPCS,outpatient,,,5766,4324.5,,4612.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3171.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2320.24,8162.33,
LAPAROSCOPIC APPENDECTOMY,400095,CDM,360,RC,44970,HCPCS,outpatient,,,5766,4324.5,,4612.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3171.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2320.24,8162.33,
LAPAROSCOPIC CHOLECYSTECTOMY,400096,CDM,360,RC,47562,HCPCS,outpatient,,,5766,4324.5,,4612.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3171.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2320.24,8162.33,
LAPCHOLE W/EXPLORATION OF COMMON DUCT,400097,CDM,360,RC,47564,HCPCS,outpatient,,,5766,4324.5,,4612.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3171.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4495.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4324.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2320.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7703.27,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4814.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2320.24,8162.33,
TNKase 50MG INJ,3200857,CDM,636,RC,J3101,HCPCS,both,,,5772,4329,,4617.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2322.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3174.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2886,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4329,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4329,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4329,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4329,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2322.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2322.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4329,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2322.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,244.96,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,229.65,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,153.1,4617.6,
CRNA-OTHER,7200050,CDM,370,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
AORTA PTA,5800024,CDM,480,RC,35472,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
BRAHIO/CEPHALIC PTA,5800029,CDM,480,RC,35475,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
FEMORAL/POPLITEAL PTA,5800072,CDM,480,RC,37224,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7708.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,12043.65,
ILIAC PTA,5800077,CDM,480,RC,37220,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7708.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,12043.65,
PTA EA ADD ART VESSEL,5800130,CDM,320,RC,75964,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
PTA PER 1ST VESSEL,5800138,CDM,320,RC,75962,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
PTA PERIPHERAL ARTERY S&I,5800139,CDM,320,RC,75962,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
PTA REN/VIS. ADD VESS,5800140,CDM,320,RC,75968,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
PTA VISCERAL/RENAL,5800149,CDM,480,RC,35471,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
PTA/VISC OR RENAL,5800151,CDM,320,RC,75966,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for radiology procedure in outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,4624,
PTCA 1ST VESSEL,5800152,CDM,480,RC,92928,HCPCS,outpatient,,,5780,4335,,4624,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19467.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19467.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19467.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3179,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4335,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2325.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15688.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2325.87,19467.86,
PTCA EACH ADD VESSEL,5800153,CDM,480,RC,92929,HCPCS,outpatient,,,5790,4342.5,,4632,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2329.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19467.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19467.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,19467.86,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2895,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3184.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4342.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4342.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4342.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4342.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2329.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2329.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4342.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2329.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2329.9,19467.86,
ER VAGINAL DELIVERY ONLY,1400217,CDM,450,RC,59409,HCPCS,outpatient,,,5802,4351.5,,4641.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2334.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3916.67,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4641.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4351.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4351.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4351.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4351.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2438.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2334.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2334.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4641.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4351.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4641.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4641.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2334.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4178.79,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2611.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4641.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4641.6,
FBR:MUSCLE DEEP/COMPLICATED,1400163,CDM,450,RC,20525,HCPCS,outpatient,,,5859,4394.25,,4687.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2357.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3710.83,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2228,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2357.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2357.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4394.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2357.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3817.9,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2386.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4687.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4687.2,
LAP SURG  PARTIAL W/END COLOSTOMY & AMP,6200610,CDM,360,RC,44206,HCPCS,outpatient,,,5940,4455,,4752,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2390.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,5940,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3267,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4455,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4455,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4455,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4455,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5940,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5940,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5940,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2390.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2390.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5940,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5940,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4455,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2390.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5940,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5940,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5940,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2390.26,12074.97,
REPLACE NON TUNNELED CV CATH >5YO,1400250,CDM,450,RC,36558,HCPCS,outpatient,,,5968,4476,,4774.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2401.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4774.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2569.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2401.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2401.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4774.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4476,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4774.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4774.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2401.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4402.75,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2751.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4774.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,4774.4,
PARTIAL REMOVAL OF COLON,6200430,CDM,510,RC,44144,HCPCS,outpatient,,,5974,4480.5,,4779.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2403.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2987,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2987,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2987,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5974,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3285.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4779.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4480.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4480.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4480.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4480.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5974,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5974,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5974,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2403.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2403.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5974,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4779.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5974,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4480.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4779.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2403.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5974,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5974,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5974,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4779.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2403.94,5974,
TOTAL ABDOMINAL HYSERECTOMY,400148,CDM,360,RC,58150,HCPCS,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3218.62,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6000,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6000,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6000,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,6000,
PTA ILIAC,5800134,CDM,480,RC,37220,HCPCS,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7708.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,12043.65,
PTA ILIAC EACH ADD,5800135,CDM,480,RC,37222,HCPCS,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,12043.65,
PTA ILIAC W/STENT,5800136,CDM,480,RC,37221,HCPCS,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15688.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,15688.84,
PTA ILIAC W/STENT EACH ADD,5800137,CDM,480,RC,37223,HCPCS,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,12043.65,
PTA TIBIA/PERONEAL,5800141,CDM,480,RC,37228,HCPCS,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15688.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,15688.84,
PTA TIBIO/PERONL W/STENT EA ADD,5800146,CDM,480,RC,37234,HCPCS,outpatient,,,6000,4500,,4800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3300,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2414.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2414.4,12043.65,
PARTIAL REMOVAL OF COLON,6200225,CDM,360,RC,44141,HCPCS,outpatient,,,6137,4602.75,,4909.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2469.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3068.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3068.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3068.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3375.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4909.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4602.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4602.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4602.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4602.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2469.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2469.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4909.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4602.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4909.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4909.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2469.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6137,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6137,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4909.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2469.53,6137,
COLECTOMY PARTIAL WITH ANASTOMOSIS W/COL,6200505,CDM,360,RC,44207,HCPCS,outpatient,,,6145,4608.75,,4916,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2472.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12074.97,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6145,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3379.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4608.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4608.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4608.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4608.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6145,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6145,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6145,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2472.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2472.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6145,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6145,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4608.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2472.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6145,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6145,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6145,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2472.75,12074.97,
GAMMAGARD  10%  30GM 300 ML,3208080,CDM,636,RC,J1569,HCPCS,both,,,6230,4672.5,,4984,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2506.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3426.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2506.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2506.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4672.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2506.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,71.13,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,44.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,66.69,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,4984,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.46,4984,
REPAIR LIVER WOUND,6200271,CDM,360,RC,47360,HCPCS,outpatient,,,6320,4740,,5056,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2543.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6320,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3476,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6320,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6320,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6320,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2543.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2543.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6320,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6320,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4740,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2543.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6320,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6320,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6320,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6320,
PRIVIGEN INTRAVENOUS SOLUTION 10% 40 GM,3203136,CDM,636,RC,J1459,HCPCS,both,,,6480,4860,,5184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2607.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3564,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2607.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2607.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4860,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2607.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.14,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,47.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,71.38,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,47.59,5184,
REVISION GASTROPLASTY,6200447,CDM,360,RC,43848,HCPCS,outpatient,,,6509,4881.75,,5207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2619.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3254.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3254.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3254.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6509,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3579.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4881.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4881.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4881.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4881.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6509,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6509,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6509,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2619.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2619.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6509,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6509,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4881.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2619.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6509,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6509,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6509,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6509,
ER PERCUTANEOUS TRACH ASP,1400155,CDM,450,RC,31612,HCPCS,outpatient,,,6548,4911,,5238.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2453.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4204.78,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2627.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,5238.4,
ER REMOVAL EMB FB ORAL CAVITY SOFT TIS,1400160,CDM,450,RC,41805,HCPCS,outpatient,,,6548,4911,,5238.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4419.87,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1197.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4911,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2634.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2051.58,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1282.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,5238.4,
I&D OF SCROTUM,1400504,CDM,450,RC,54700,HCPCS,outpatient,,,6559,4919.25,,5247.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2639.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4427.19,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4919.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4919.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4919.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4919.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,1599.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2639.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2639.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4919.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2639.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2741.39,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,1713.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,5247.2,
HARMONIC CURVED SHEARS 36/23,9000446,CDM,270,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
INSERTION-TEMP PACEMAKER SINGLE CHAMBER,5800091,CDM,480,RC,33211,HCPCS,outpatient,,,6596,4947,,5276.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2654.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3627.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4947,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4947,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4947,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4947,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2654.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2654.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4947,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2654.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12064.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12064.12,
KCL MED DRESSING,9000966,CDM,270,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
KCL CANISTER,9000967,CDM,270,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
KCL ABD DRESSING,9000968,CDM,270,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
STENT EXIENCE ELUTING,9000990,CDM,278,RC,,,both,,,4950,3712.5,,3960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2722.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3465,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1991.88,3960,
HOMER BREAST BIOPSY LOCALIZATION NEEDLE,9999332,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
DIAMONDBACK 125 MICRO 145,5890107,CDM,278,RC,C1724,HCPCS,both,,,6790,5092.5,,5432,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3734.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4753,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2732.3,5432,
DIAMONDBACK 360 2.00 SOLID CROWN,90007896,CDM,278,RC,C1724,HCPCS,both,,,6790,5092.5,,5432,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3734.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4753,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5092.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2732.3,5432,
PACEMAKER ASSURITY MRI UMRI PR,5890006,CDM,278,RC,C1786,HCPCS,both,,,6800,5100,,5440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3740,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2736.32,5440,
EXPLORE CHEST VESSELS,6200575,CDM,360,RC,35820,HCPCS,outpatient,,,6800,5100,,5440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3740,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2736.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6800,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,6800,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6800,
"Hysteroscopy, surgical; with endo",6100573,CDM,521,RC,58563,HCPCS,outpatient,,,6807,5105.25,,5445.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2739.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6127.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6127.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6127.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3743.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5105.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5105.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5105.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5105.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2739.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2739.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5105.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2739.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6850.42,
ATTESTA IPG DR MRI SURESCAN,5890113,CDM,275,RC,C1722,HCPCS,outpatient,,,6900,5175,,5520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2776.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3795,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2776.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2776.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4830,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5175,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2776.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5520,
PTA FEM/POP,5800131,CDM,480,RC,37224,HCPCS,outpatient,,,7000,5250,,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3850,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7708.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12043.65,
RT HEART & LHC,5800171,CDM,480,RC,93526,HCPCS,outpatient,,,7007,5255.25,,5605.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2819.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3853.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5605.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5255.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5255.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5255.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5255.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2819.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2819.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5605.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5255.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5605.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5605.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2819.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5605.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5605.6,
INTERUPTION OF IVC,5800093,CDM,480,RC,37191,HCPCS,outpatient,,,7242,5431.5,,5793.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2914.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9865.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9865.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9865.8,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3983.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5431.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5431.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5431.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5431.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2914.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2914.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5431.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2914.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9865.8,
HIP STEM SECUR-FIT ADV. V40,890251,CDM,278,RC,C1776,HCPCS,both,,,7257.36,5443.02,,5805.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2920.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,0.01,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,3628.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3991.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3628.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3628.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3628.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3628.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3628.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3628.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5805.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5443.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5443.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5443.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5443.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2920.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2920.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5080.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5443.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5805.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5805.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2920.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5805.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.01,5805.89,
IPG W3DR01 AZURE SURESCAN DR MRI,90008348,CDM,278,RC,33213,HCPCS,both,,,7400,5550,,5920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2977.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4070,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5550,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5550,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5550,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5550,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2977.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2977.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5550,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2977.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,5920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2977.76,15265.35,
HAWK ONE DIRECTIONAL ATHERECTOMY SYSTEM,5890084,CDM,278,RC,C1714,HCPCS,both,,,7474.5,5605.88,,5979.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3007.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4110.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3737.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5979.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5605.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5605.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5605.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5605.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3007.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3007.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5232.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5605.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5979.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5979.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3007.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5979.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3007.74,5979.6,
PTA TIBIO/PERONL W/STENT/ATHRE EA ADD,5800148,CDM,480,RC,37235,HCPCS,outpatient,,,7500,5625,,6000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12043.65,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4125,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12043.65,
LEADS DURATACHY MRI UMRI PR 7122Q/58,5890106,CDM,278,RC,C1760,HCPCS,both,,,7500,5625,,6000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4125,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5250,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3018,6000,
ATHERECTOMY H1-14550 CUTTER DRIVER V03,90006889,CDM,270,RC,C1714,HCPCS,outpatient,,,7500,5625,,6000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4125,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5625,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3018,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6000,
PACEMAKER ASSURITY PM2240,5890052,CDM,275,RC,C1785,HCPCS,outpatient,,,7600,5700,,6080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3058.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4180,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3058.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3058.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3058.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6080,
PLACEMENT TUN CENT VEN CATH <AGE5,1400227,CDM,450,RC,36557,HCPCS,outpatient,,,7862,5896.5,,6289.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3163.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4028.35,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,900,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5896.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5896.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5896.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5896.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3163.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3163.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5896.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3163.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,900,7596.28,
MAALOX 30ML LIQUID,60000353,CDM,250,RC,,,outpatient,,,2,1.5,,1.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.8,1.6,
INCISION & DRAINAGE OF ABSCESS; SIMPLE,65010060,CDM,982,RC,10060,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,65.58,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,65.58,65.58,
PRO FEE DEBRIDEMENT WOUND CLINIC,65011042,CDM,982,RC,11042,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,45.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,45.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,45.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,45.27,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,45.27,45.27,
CALLUS REDUCTION WOUND CARE,65011055,CDM,982,RC,11055,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,28.85,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,28.85,28.85,
PRO FEE REMOVAL OF BENIGN LESION; 2-4,65011056,CDM,982,RC,11056,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,35.57,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,35.57,35.57,
CHEMICAL CAUTERIZATION OF GRAN TISSUE,65017250,CDM,510,RC,17250,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,201.03,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,266.88,
PRO FEE DEBRID NECROTIC TISSUE < 20 SQ C,65097597,CDM,982,RC,97597,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,38.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,38.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,38.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,38.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,38.65,38.65,
Negative Pressure Therapy <50 sq cm,65097605,CDM,510,RC,97605,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,160.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,160.73,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,155.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charges,,,,,other,Not separately reimbursable for outpatient setting due to charges,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charges,266.88,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,166.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,250.2,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,155.74,266.88,
"Hysteroscopy, surgical; remove leiomy",6100712,CDM,521,RC,58561,HCPCS,outpatient,,,8200,6150,,6560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3299.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6127.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6127.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6127.37,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4510,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3997.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3299.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3299.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,3299.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6850.42,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4281.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,6850.42,
LT HT CATH/RETRO,5800104,CDM,480,RC,93458,HCPCS,outpatient,,,8324,6243,,6659.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3349.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4578.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3349.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3349.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3349.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
NEW PT VISIT LVL 2 -PRO,65099202,CDM,982,RC,99202,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,42.77,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,42.77,42.77,
PRO FEE NEW PAT DETAILED WOUND CARE,65099203,CDM,982,RC,99203,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.18,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,62.18,62.18,
PRO FEE WOUND CARE EST PAT COMP,65099204,CDM,982,RC,99204,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,96.56,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,96.56,96.56,
PRO FEE NEW PAT COMP WOUND CLINIC,65099205,CDM,982,RC,99205,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,122.19,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,122.19,122.19,
PRO FEE EST PAT PROB FOCUSED WOUND CLINI,65099212,CDM,982,RC,99212,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,24.83,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,24.83,24.83,
PRO FEE WOUND CARE EST PAT EXPADED,65099213,CDM,982,RC,99213,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,41.53,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,41.53,41.53,
PRO FEE EST PT DETAILED WOUND CARE,65099214,CDM,982,RC,99214,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,62.65,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,62.65,62.65,
PRO FEE EST PT COMP WOUND CARE,65099215,CDM,982,RC,99215,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,84.93,100,,,fee schedule,100% LA Medicaid fee schedule for physician setting,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting per CMS guidelines,,,,,other,Not separately reimbursable for physician setting,84.93,84.93,
ANGIO CORNRY ART/S&I,5800021,CDM,480,RC,93454,HCPCS,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
L HRT/ART/GRFT/ANGIO,5800098,CDM,480,RC,93459,HCPCS,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
LT HEART CATH,5800103,CDM,480,RC,93452,HCPCS,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
ADAPTER VIALMATE,80000001,CDM,270,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
ALCOHOL LARGE PREP PAD,80000003,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
SLING ARM CHILD,80000009,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
SLING ARM PEDIATRIC,80000010,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
"BEDPANS, FRACTURE",80000024,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
DONT USE BELT RIB LARGE MALE,80000025,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BELT RIB LG. FEMALE,80000026,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DONT USE BELT RIB MED. FEMALE,80000027,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DONT USE BELT RIB MED. MALE,80000028,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BELT RIB SM. FEMALE,80000029,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BELT RIB SM. MALE,80000030,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DONT USE BELT RIB XL MALE,80000031,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DONT USE BELT RIB XL. FEMALE,80000032,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BETADINE SWABSTICKS 1202,80000034,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
"DONT USE CERVICAL COLLAR, MEDIUM",80000081,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CERVICAL COLLAR SMALL,80000082,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CERVICAL COLLAR LARGE,80000084,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CERVICAL COLLAR MEDIUM,80000085,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CERVICAL COLLAR XL,80000086,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CLAVICLE STRAP MEDIUM,80000101,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CLAVICLE STRAP SMALL,80000102,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CLAVICLE STRAP CHILD,80000103,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CLAVICLE STRAP LARGE,80000104,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CERVICAL COLLAR X-SMALL,80000109,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
DONT USE COLLAR  SOFT CERVICAL PEDIATRIC,80000110,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
COTTON TIPPED APP. STERILE,80000119,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
"COVERS, THERMOMETER PROBE ORAL",80000122,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
CROTCH SUPPORT LARGE,80000123,CDM,270,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
CROTCH SUPPORT MEDIUM,80000124,CDM,270,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
CROTCH SUPPORT SMALL,80000125,CDM,270,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
CROTCH SUPPORT X-LARGE,80000126,CDM,270,RC,,,outpatient,,,43,32.25,,34.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.3,34.4,
"CRUTCHES, MEDIUM/ADULT",80000127,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
"CRUTCHES, SMALL/YOUTH",80000128,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
"CRUTCHES, TALL/ADULT",80000129,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
"CUP, MEDICINE PLASTIC 1OZ",80000132,CDM,270,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
DENTURE CUPS,80000136,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
DEODORANT ROLL-ON MSC095010,80000137,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
DIAPER LARGE BLUE W/ELASTIC,80000138,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DISPOSABLE SURGICAL CAUTERY   AA21,80000147,CDM,270,RC,,,outpatient,,,32.6,24.45,,26.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.12,26.08,
DONT USE DRAPE SHEETS 41X70,80000152,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DRAPE SHEETS MEDIUM,80000153,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
ELECTRODE BLADE LONG TIPS E1551-6,80000162,CDM,270,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
EMESIS BAGS,80000166,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
EMESIS BASINS,80000167,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
FENESTRATED DRAPES,80000187,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
GLOVES NITRILE EXAM LG,80000204,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
GLOVES NITRILE EXAM XL,80000205,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
GLOVES NITRILE EXAM SM,80000206,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
GLOVES NITRILE EXAM MEDIUM,80000208,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
CLAVICLE STRAP INFANT,80000242,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
GAUZE IDOFORM PACKING 1/2 X 5,80000262,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
DONT USE IV-NSS IRRIGATION 3000ML,80000266,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
J-SPLINT PLASTER ROLL 3,80000268,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
J-SPLINT PLASTER ROLL 4,80000269,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
J-SPLINT PLASTER ROLL 5,80000270,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
KITS-RMC ADMIT,80000274,CDM,270,RC,,,outpatient,,,12.81,9.61,,10.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.15,10.25,
KLEENEX BEDSIDE,80000275,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
KNEE IMMOBILIZER 18,80000276,CDM,270,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
KNEE IMMOBILIZER 20,80000277,CDM,270,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
KNEE IMMOBILIZER 22,80000278,CDM,270,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
KNEE IMMOBILIZER 24,80000279,CDM,270,RC,,,outpatient,,,58,43.5,,46.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.34,46.4,
LANCETS FINGERSTIX,80000285,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
LAP DRAPE W/POUCHES,80000286,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
SPLINT WRIST PADDED LT MEDIUM,80000288,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
LOTION HAND/BODY 2 OZ,80000292,CDM,270,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
SPLINT WRIST PADDED LT LARGE,80000293,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
SPLINT WRIST PADDED RT MED,80000309,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
"MIDSTREAMS, W/BZK URINE COLLECT",80000310,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
MOUTHWASH FRESH & KLEEN 4,80000317,CDM,270,RC,,,outpatient,,,0.49,0.37,,0.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.27,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.2,0.39,
NEEDLE BUTTERFLY 21GA 3/4,80000320,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
NEEDLE (ECLIPSE) 23G X 1,80000325,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NEEDLE (ECLIPSE) 25G X 1,80000326,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
NEEDLE PRECISION GLIDE HYPO. 19G X1,80000329,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
NEEDLE 25G X 1 1/2 (305127),80000330,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
NEEDLE 22G X 1 1/2 MONOJECT,80000334,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
NEEDLES 21 G (305165),80000338,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
NEEDLE BUTTERFLY 23GA 3/4 12,80000339,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NSS HYPERTONIC 3%,80000343,CDM,270,RC,,,outpatient,,,3.61,2.71,,2.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.45,2.89,
PADS PREPPING,80000347,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
"PILLOW, DISPOSABLE",80000366,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"RAZORS, 2-SIDED PREPPING",80000388,CDM,270,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
"SHAMPOO, BABY/BODY WASH 2OZ",80000409,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
SHAVE CREAM 1.5OZ,80000421,CDM,270,RC,,,outpatient,,,0.35,0.26,,0.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.28,
SHOE SURGICAL MEN LARGE,80000425,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
SHOE SURGICAL MEN MEDIUM,80000426,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SHOE SURGICAL MEN SMALL,80000427,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SHOE SURGICAL WOMEN LARGE,80000428,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
SHOE SURGICAL WOMEN MEDIUM,80000429,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SHOE SURGICAL WOMEN SMALL,80000430,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SHOULDER IMMOBILIZER LARGE,80000432,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
SHOULDER IMMOBILIZER MEDIUM,80000433,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
SHOULDER IMMOBILIZER SMALL,80000434,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
SLING ARM LARGE,80000435,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
SLING ARM SMALL,80000436,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
SLING ARM EXTRA LARGE,80000437,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
SLING ARM MEDIUM,80000438,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
SPLINT WRIST/FOREARM RT LG,80000446,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
"SPLINT, TIB/FIB LARGE",80000451,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
"SPLINT, TIB/FIB MEDIUM",80000452,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
"SPLINT, TIB/FIB SMALL",80000453,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
TAPE MEDIPORE 2X10,80000478,CDM,270,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
TAPE MEDIPORE 3X10,80000479,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
"TAPE, DURAPORE 1   SILK",80000484,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
"TAPE, DURAPORE 3   SILK",80000486,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
"TAPE, MICROPORE 1  (PAPER)",80000495,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
TRACH TUBE HOLDER SECURE,80000519,CDM,270,RC,,,outpatient,,,5.2,3.9,,4.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.86,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.09,4.16,
ULNAR PROTECTOR  BLUE FOA,80000524,CDM,270,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
"WIPES, SKIN PREP OSTOMY",80000527,CDM,270,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
SPLINT WRIST/FOREARM LT XL,80000529,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SPLINT WRIST/FOREARM LT SM,80000530,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SPLINT WRIST/FOREARM LT MED,80000531,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SPLINT WRIST/FOREARM LT LG,80000532,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SPLINT WRIST/FOREARM LT PED,80000533,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SPLINT WRIST/FOREARM RT MED,80000534,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SPLINT WRIST/FOREARM RT XL,80000535,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
XS/CHILD CLAVICLE STRAP,80000536,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
ABDOMINAL BINDER LARGE,90000010,CDM,270,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
ADULT 02 MASK MED CONC. W/ TUBING,90000023,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
AMBU BAGS ADULT RESUSCITA,90000041,CDM,270,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
AMBU BAGS RESUSCITATOR IN,90000042,CDM,270,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
AMBU BAGS RESUSCITATOR PE,90000043,CDM,270,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
RT & LHC W/CORNRY/ VENT,5800168,CDM,480,RC,93460,HCPCS,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
ANTI-FOG KIT,90000064,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
APPLIER CLIP MCS20,90000067,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
APPLIER CLIP MSM20,90000068,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
ARM SLING EXTRA LARGE (DO NOT ORDER),90000073,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
AUTOSUTURE ENDOCLOSE,90000082,CDM,270,RC,,,outpatient,,,288,216,,230.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,115.89,230.4,
ARTERIAL BLOOD GAS KIT 3113663160,90000087,CDM,270,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
BALLARD SUCTI0N KITS,90000096,CDM,270,RC,,,outpatient,,,13.36,10.02,,10.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.38,10.69,
BANDAGE 2  ACE DYN3652,90000112,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
BANDAGE 4  ACE DYN3664,90000113,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
BANDAGE 6 ACE DYN3666,90000114,CDM,270,RC,,,outpatient,,,7.5,5.63,,6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.02,6,
BANDAGE ACE 3 DYN3113,90000115,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
BELT RIB MALE MEDIUM,90000148,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
"BIOPSY FORCEPS, HOT FD210U",90000174,CDM,270,RC,,,outpatient,,,110,82.5,,88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.26,88,
"BIOPSY FORECEPS, COLD FB220-U.A",90000175,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
DO NOT USE BIOPSY NEEDLES 15 GA EASY,90000177,CDM,270,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
BIOPSY PUNCH MILTEX 2MM,90000178,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
BIOPSY VALVE MAJ-210,90000179,CDM,270,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
BITE BLOCKS GIS-3M,90000181,CDM,270,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
BLADES CLIPPER BLUE,90000185,CDM,270,RC,,,outpatient,,,5.31,3.98,,4.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.14,4.25,
BLAKE DRAIN 10 FRENCH,90000186,CDM,270,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
DO NOT ORDER BLANKET LOWER BODY,90000188,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
WARMING BLANKET FULL BODY,90000189,CDM,270,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
DO NOT ORDER BLANKET UPPER BODY WARMING,90000190,CDM,270,RC,,,outpatient,,,17,12.75,,13.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.84,13.6,
BLUE TOP COAGULATION VACUETTE,90000197,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BONE WAX W31G,90000199,CDM,270,RC,,,outpatient,,,14.55,10.91,,11.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.85,11.64,
BOOTIES VASCULAR,90000208,CDM,270,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
BOTTLES VACUUM,90000209,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
BREATHING TUBE AIR-MATE 3,90000226,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BULB JACKSON PRATT,90000230,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
CANISTERS V.A.C,90000251,CDM,270,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
CANNULA 11X100 TROCAR,90000252,CDM,270,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
CASSETTE OPTI B BP7562,90000286,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATH LAB PACK,90000290,CDM,270,RC,,,outpatient,,,75.22,56.42,,60.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.37,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.27,60.18,
CATHERE F4 INF JL5 100CM,90000293,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHERE FRENCH4 INF JL4 10,90000295,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER ANGIOGRAPHIC 465354RBI,90000297,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
CATHETER CORONARY 1011392-12,90000311,CDM,270,RC,,,outpatient,,,630,472.5,,504,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,346.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.51,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,253.51,504,
CATHETER DIAGNOSTIC LCB 4FR,90000319,CDM,278,RC,,,both,,,16.7,12.53,,13.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.72,16.7,
CATHETER DIAGNOSTIC 538-445,90000321,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER DIAGNOSTIC JR4 538-421,90000323,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER GUIDE LIMA,90000330,CDM,270,RC,,,outpatient,,,222,166.5,,177.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,89.33,177.6,
CATHETER GUIDE RENAL DOUBLW,90000332,CDM,270,RC,,,outpatient,,,222,166.5,,177.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,89.33,177.6,
CATHETER GUIDING 6F 1001900-06,90000338,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
RT HEART CATH,5800172,CDM,480,RC,93457,HCPCS,outpatient,,,8500,6375,,6800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4675,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3420.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,6800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
CATHETERDIAGNOSTIC,90000352,CDM,270,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
CATHETERS FOGARTY 120803F,90000353,CDM,270,RC,,,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
CATHETERS FOGARTY 120805F,90000354,CDM,270,RC,,,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
CATHETERS FOGARTY 120602F,90000355,CDM,270,RC,,,outpatient,,,105.5,79.13,,84.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.45,84.4,
CATHETERS FOGARTY 120804F,90000356,CDM,270,RC,,,outpatient,,,105.5,79.13,,84.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.45,84.4,
CATHETERS FOGARTY 120806F,90000357,CDM,270,RC,,,outpatient,,,105.5,79.13,,84.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.45,84.4,
CATHETERS FOGARTY 120807F,90000358,CDM,270,RC,,,outpatient,,,182,136.5,,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,73.24,145.6,
CHROMIC GUT 4-0 ON RB-1 N,90000373,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
CLEANER CAUTERY TIP,90000378,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CLIP APPLIER ENDO 10MM DI,90000383,CDM,270,RC,,,outpatient,,,530,397.5,,424,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,213.27,424,
CLIPPERS SURGICAL,90000385,CDM,270,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
DO NOT USECOBAN STRETCH 3 X 5YD WRAP,90000394,CDM,270,RC,,,outpatient,,,10.5,7.88,,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.23,8.4,
"COLLAR, STIFNECK ADULT SEL",90000398,CDM,270,RC,,,outpatient,,,11.64,8.73,,9.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.68,9.31,
"COLLAR, STIFNECK BABY NO-NECK",90000399,CDM,270,RC,,,outpatient,,,11.56,8.67,,9.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.65,9.25,
"COLLAR, STIFNECK NO-NECK",90000400,CDM,270,RC,,,outpatient,,,13.88,10.41,,11.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.59,11.1,
"COLLAR, STIFNECK PEDIATRIC 980200",90000401,CDM,270,RC,,,outpatient,,,12.16,9.12,,9.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.89,9.73,
"COLLAR, STIFNECK PEDI-SEL 980020",90000402,CDM,270,RC,,,outpatient,,,24.64,18.48,,19.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.92,19.71,
"COLLAR, STIFNECK REGULAR",90000403,CDM,270,RC,,,outpatient,,,12.16,9.12,,9.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.89,9.73,
"COLLAR, STIFNECK SHORT",90000404,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
"COLLAR, STIFNECK TALL",90000405,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
ACTIVASE 100MG INJ,3201054,CDM,636,RC,J2997,HCPCS,both,,,8795.25,6596.44,,7036.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3539.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4837.39,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4397.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7036.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6596.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6596.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6596.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6596.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3539.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3539.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7036.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6596.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7036.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7036.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3539.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.65,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,133.74,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7036.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,89.16,7036.2,
INSERTION-TEMP PACEMAKER DUAL CH FOR PRO,5800090,CDM,480,RC,33211,HCPCS,outpatient,,,8856,6642,,7084.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4870.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12064.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12064.12,
PACER SINGLE CHAMBER LEAD ONLY,5800118,CDM,480,RC,33216,HCPCS,outpatient,,,8856,6642,,7084.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,6481.44,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4870.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6642,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3563.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12064.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12064.12,
INSERTION SUBCUTANEOUS CARDIAC RHY MONIT,5800047,CDM,480,RC,33285,HCPCS,outpatient,,,8994,6745.5,,7195.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3619.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9995.55,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9995.55,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9995.55,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4946.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6745.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6745.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6745.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6745.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3619.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3619.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6745.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3619.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12064.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12064.12,
COUNTER NEEDLE 20 COUNT,90000454,CDM,270,RC,,,outpatient,,,11.5,8.63,,9.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.63,9.2,
COVER LIGHT HANDLE SURGERY,90000456,CDM,270,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
"CURETTE, CERA SPOON BION6333",90000478,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"CURETTE, EAR  3MM BION1222",90000479,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CUTTER ENDO LINER REG BLU,90000483,CDM,270,RC,,,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,600,
CUTTER LINEAR TLC55,90000484,CDM,270,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
DO NOT USE CUTTER LINEAR TITANIUM 55,90000485,CDM,270,RC,,,outpatient,,,262.34,196.76,,209.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,131.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.29,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,105.57,209.87,
CUTTER LINEAR TITANIUM 75,90000486,CDM,270,RC,,,outpatient,,,512,384,,409.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,281.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.03,409.6,
CUTTER RELOAD TR45W,90000487,CDM,270,RC,,,outpatient,,,365,273.75,,292,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.88,292,
DO NOT USE DERMA-FLEX,90000495,CDM,270,RC,,,outpatient,,,103,77.25,,82.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,41.45,82.4,
DERMAL WOUND CLEANER  8OZ,90000496,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
DEVICE VASCULAR CLOSURE MYNX 6FR/7FR,90000505,CDM,270,RC,,,outpatient,,,370,277.5,,296,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,185,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,203.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,148.89,296,
DO NOT USE BIOPATCH DISK,90000517,CDM,270,RC,,,outpatient,,,7,5.25,,5.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.82,5.6,
DISP. CAUTERY LOOP TIP,90000519,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
DO NOT USE DISPOSABLE CAUTERY,90000524,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
PESSARY DONUT 3 1/4 (PESSARY ONLY),90000528,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY DONUT 3 1/2 (PESSARY ONLY),90000529,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY DONUT 2 (PESSARY ONLY),90000531,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY DONUT 2 1/4 (PESSARY ONLY),90000532,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY GELLHORN 3 1/4 (PESSARY ONLY),90000533,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY DONUT 3 3/4 (PESSARY ONLY),90000534,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
DRAIN CHANNEL 19FR,90000539,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
DRAIN MALECOT 18FR,90000540,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
DRAIN MALECOT 20FR,90000541,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
DRAIN MALECOT 22FR 4-WING,90000542,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
DRAIN MALECOT 24FR,90000543,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
DRAIN MALECOT 4-WING 10 F,90000544,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
DRAIN MALECOT 4-WING 14FR,90000545,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
DRAPE INCISE IOBAND 2,90000548,CDM,270,RC,,,outpatient,,,239,179.25,,191.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.17,191.2,
DRAPE PLAIN 18X26,90000549,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
DURAPREP SOLUTION,90000568,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
EAR & ULCER SYRINGE 2.5OZ,90000569,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
ELECTRODE BLADE LONG TIPS E1560,90000580,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
ELECTRODE BLADE LONG TIPS E1561,90000581,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
ELECTRODE BLADE LONG TIPS E1564,90000582,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
ENDO PEANUTS 173019,90000591,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
ESOPHAGEAL STETHSCOPE 18 ES18400,90000600,CDM,270,RC,,,outpatient,,,14.5,10.88,,11.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.83,11.6,
EVEROLIMUS ELUTING CORONARY 1009543-12,90000608,CDM,270,RC,,,outpatient,,,3300,2475,,2640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1815,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1327.92,2640,
"EXHALATION PORT, DISPOSABLE",90000613,CDM,270,RC,,,outpatient,,,43.5,32.63,,34.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.5,34.8,
E-Z PAQUE BA SULFATE CUPS,90000617,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
FORCEPS HOT BX DISPOSABLE SD-240U-15,90000666,CDM,270,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
GASTROGRAFIN 12X120ML,90000681,CDM,270,RC,,,outpatient,,,28.9,21.68,,23.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.63,23.12,
GEN DISPOSABLE SCISSORE 5MMX33CM,90000688,CDM,270,RC,,,outpatient,,,189,141.75,,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.05,151.2,
GIGLI SAW BLADE 12INCH EN,90000691,CDM,270,RC,,,outpatient,,,37.5,28.13,,30,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.09,30,
GLOVES BIOGEL SZ 6,90000697,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
GUIDE LINER V3 CATHETER 6FR,90000719,CDM,270,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
PACEMAKER-DUEL/ SINGLE CHAMBER,5800111,CDM,275,RC,C1785,HCPCS,outpatient,,,9000,6750,,7200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4950,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7200,
GYNECOLOGIC KIT,90000743,CDM,270,RC,,,outpatient,,,948,711,,758.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,381.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,474,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,521.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,381.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,711,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,758.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,381.48,758.4,
INSTANT HAND SANITIZER 2 LITER,90000749,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
HOOK LAPROSCOPIC WIRE,90000777,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
INSUFFLATOR NEEDLE 120MM,90000811,CDM,270,RC,,,outpatient,,,43.5,32.63,,34.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.5,34.8,
PACEMAKER ASSURITY PM2272,5890008,CDM,275,RC,C1785,HCPCS,outpatient,,,9000,6750,,7200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4950,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7200,
PACEMAKER ASSURITY PM2240 SYSTEM,5890035,CDM,275,RC,C1785,HCPCS,outpatient,,,9000,6750,,7200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4950,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7200,
RT & LT CATH W/CORNRY/VENT/GRAFTS,5800169,CDM,480,RC,93461,HCPCS,outpatient,,,9500,7125,,7600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5225,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
IV CATH 18GA X 1 JJ3075,90000827,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
IV CATH 20 GA X 1 JJ3077,90000828,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
IV CATH 24 GA X 5/8 JJ3073,90000829,CDM,270,RC,,,outpatient,,,4.65,3.49,,3.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.56,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.87,3.72,
J TUBE JEJUNAL FEEDING,90000833,CDM,270,RC,,,outpatient,,,185,138.75,,148,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,74.44,148,
KIT COOK EMERGENCY PNEUMOTHORAX,90000849,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
KIT CUSTOM MANIFOLD BT2000,90000850,CDM,270,RC,,,outpatient,,,36.4,27.3,,29.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.02,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.65,29.12,
KIT INITIAL PEG PLACEMENT,90000853,CDM,270,RC,,,outpatient,,,195,146.25,,156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,78.47,156,
KIT INTRODUCER KIT FOR PICC LINE,90000854,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
KIT PROXIMATE PPH03,90000856,CDM,270,RC,,,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2080,
KITS ANGIO HAND CONTROL,90000861,CDM,270,RC,,,outpatient,,,54,40.5,,43.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,21.73,43.2,
KITS BLOOD GAS,90000862,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DONT USE LARGE COMPRESSION SLEEVES,90000941,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
LARGE VAGINAL SPECULUM,90000944,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"LENS, MORGAN MEDI-FLOW STERILE",90000952,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
LIGACLIP CLIP APPLIER LARGE,90000960,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
LMA 1-1.5,90000971,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
LMA SIZE 2 DISPOSABLE,90000976,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
LMA SIZE 2.5 DISPOSABLE,90000977,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
DO NOT USE VALVE BIOPSY SINGLE USE,90000987,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
SUCTION VALVE MAJ-209,90000988,CDM,270,RC,,,outpatient,,,23.26,17.45,,18.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.79,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.36,18.61,
MARKER SPOT ENDOSCOPIC,90000991,CDM,270,RC,,,outpatient,,,58.5,43.88,,46.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.18,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.54,46.8,
MASK AEROSOL W/6' TUBING,90000992,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
MASK COMFORT CLASSIC M,90000993,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
MASK COMFORT CLASSIC S,90000994,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
MASK CONTOUR DELUXE SM,90000995,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
MASK FACE ADULT,90000996,CDM,270,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
MASK FACE SM ADULT,90000997,CDM,270,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
MASK NASAL LAR/NAR,90000998,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
MASK NON INV VENTILATION,90000999,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
MASK PED 3-IN-1 C/SAFETY,90001000,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
MASK PEDIATRIC AERESOL,90001001,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"MASK, AEROSOL ADULT VINYL",90001003,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"MASK, AEROSOL PEDIATRIC D",90001004,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"MASK, NASAL MED/LG ADULT BIP",90001008,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
MESH  10X15,90001031,CDM,270,RC,,,outpatient,,,1100,825,,880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,605,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,442.64,880,
MESH 15X19,90001032,CDM,270,RC,,,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,885.28,1760,
MESH 3X6,90001033,CDM,270,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
MESH DUALMESH PLUS 18X24,90001038,CDM,270,RC,,,outpatient,,,2200,1650,,1760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1210,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1650,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,885.28,1760,
MESH DUALPLUS 8X12,90001039,CDM,270,RC,,,outpatient,,,1100,825,,880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,605,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,442.64,880,
MESH SHEET FLAT 6 X 6  ST,90001042,CDM,270,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
MICROCUVETTES HB201,90001049,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
MINI TREK CORONARY CATHETER,90001054,CDM,270,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
MULTISTIX REAGENT STRIP FOR AE2161,90001072,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NEBULIZER KIT HANDHELD W/7' TUBING,90001079,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NEBULIZER W/7' SUPPLY TUB,90001081,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
NEEDLE 25G X 1 1/2 BD305767,90001092,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
DO NOT USE NEEDLE BLUNT FILLED 18GX1,90001095,CDM,270,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
NEEDLE INSUFFLATION C2202,90001100,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
NEEDLE INTRAOSSEOUS INFUSE 4.0,90001102,CDM,270,RC,,,outpatient,,,80.98,60.74,,64.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.59,64.78,
NEEDLES 22G X 1,90001108,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
CATHETER SYS NEXIVA 20G 1,90001114,CDM,270,RC,,,outpatient,,,190,142.5,,152,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,76.46,152,
RT & LT HEART CATH,5800170,CDM,480,RC,93453,HCPCS,outpatient,,,9500,7125,,7600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,8687.74,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5225,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,2551.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4372.43,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,2732.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8687.74,
PACK ANGIOPLASTY,90001176,CDM,270,RC,,,outpatient,,,129,96.75,,103.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.91,103.2,
PADS QUICK COMBO FOR LIFE,90001186,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
PEDIATRIC MED CONC. 02 MA,90001203,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
PED. 02 CENSOR,90001204,CDM,270,RC,,,outpatient,,,70,52.5,,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.17,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,28.17,56,
PEG 24 PULL,90001209,CDM,270,RC,,,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
PEG TUBE   REPLACEMENT  1,90001210,CDM,270,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PEG TUBE   REPLACEMENT 20,90001211,CDM,270,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PEG TUBE  REPLACEMENT 24F,90001212,CDM,270,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
PERFORMAX HEAD GEAR LG,90001225,CDM,270,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
PERFORMAX HEAD GEAR SMALL,90001226,CDM,270,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
PICC LINES SOLO DOT,90001234,CDM,270,RC,,,outpatient,,,705,528.75,,564,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,352.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,387.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,283.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,528.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,283.69,564,
"Laparoscopy, surgical, with vaginal hyst",6100575,CDM,521,RC,58554,HCPCS,outpatient,,,9588,7191,,7670.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3858.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8162.33,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5273.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7837.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3858.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3858.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7191,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,3858.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13430.53,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,8394.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,13430.53,
POUCH RETRIEVAL SYS. ENDO,90001252,CDM,270,RC,,,outpatient,,,507,380.25,,405.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,253.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,278.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,204.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,204.02,405.6,
PRESSURE MONITOR KIT PXVMP272,90001263,CDM,270,RC,,,outpatient,,,187.04,140.28,,149.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,93.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.87,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,75.26,149.63,
PREVENA INCISION MANAGEMENT,90001264,CDM,270,RC,,,outpatient,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,560,
PROTECTIVE SYSTEM IV CATH 22G,90001277,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
PUNCH BIOPSY DISP 4MM,90001286,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
PUNCH BIOPSY DISP 3MM,90001287,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
PUNCH DISPOSABLE BIOPSY ASSORTED,90001288,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
PURPLE TOP VACUETTE BLOOD,90001294,CDM,270,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
READYBATH SCENTED,90001307,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
RELOAD LINEAR STAPLER TR90,90001322,CDM,270,RC,,,outpatient,,,216.5,162.38,,173.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.12,173.2,
RELOAD CARTRIDGE FOR TR60,90001323,CDM,270,RC,,,outpatient,,,216.5,162.38,,173.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.12,173.2,
"REMOVER, SKIN STAPLES",90001324,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
RHINO ROCKET NASAL PACKING 11S-S0800,90001340,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
RHINO ROCKET NASAL PACKING 11S-S0500,90001341,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
RHINO ROCKET NASAL PACKING 11S-S0300,90001342,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
SCALPEL #10,90001372,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SCALPEL #11,90001373,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SCALPEL STERILE  #15,90001374,CDM,270,RC,,,outpatient,,,5.5,4.13,,4.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.21,4.4,
SCLEROTHERAPY NEEDLE,90001383,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
SET CATHERIZATION ANGIOGRAPHIC,90001396,CDM,270,RC,,,outpatient,,,74.4,55.8,,59.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.94,59.52,
SET TRANSFER VALVE SVTS,90001398,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
SKIN STAPLERS ROYAL 35W,90001426,CDM,270,RC,,,outpatient,,,52.17,39.13,,41.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.69,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.99,41.74,
DO NOT USE SMALL VAGINAL SPECULUM,90001439,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SMARTPORTS CT96STSD,90001440,CDM,278,RC,,,both,,,1100,825,,880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,605,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,770,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,442.64,880,
SMARTSETS (MRI),90001441,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SNARE DISPOSABLE 15MM,90001444,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
"SNARE, POLYPECTOMY",90001445,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SORBFX 15CT LAPROSCOPIC,90001461,CDM,270,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
SPECULA DISP. SIGMOIDOSCOPE,90001464,CDM,270,RC,,,outpatient,,,16.5,12.38,,13.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.64,13.2,
SPECULA VAGINAL KLEENSPEC MEDUIM,90001465,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
"SPIROMETER, INCENTIVE 400",90001478,CDM,270,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
SPONGE GAUZE 4X4,90001496,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
DONT USE STANDARD LINED SLEEVES 12,90001530,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
STAPLE CARTRIDGE LINEAR 5 TCR55,90001532,CDM,270,RC,,,outpatient,,,229,171.75,,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,92.15,183.2,
DO NOT USE STAPLE CARTRIDGE LINEAR 5,90001533,CDM,270,RC,,,outpatient,,,216.5,162.38,,173.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.08,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,87.12,173.2,
STAPLE CARTRIDGE LINEAR 5 TL60,90001534,CDM,270,RC,,,outpatient,,,433,324.75,,346.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,174.24,346.4,
STAPLE CARTRIDGE LINEAR TCR75,90001535,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
STAPLER  LANIER ETS-FLEX4,90001537,CDM,270,RC,,,outpatient,,,495,371.25,,396,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,247.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,199.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,371.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,199.19,396,
STAPLER CURVED CS40G,90001538,CDM,270,RC,,,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,720,
STAPLER LANIER RELOAD 6R45B,90001539,CDM,270,RC,,,outpatient,,,365,273.75,,292,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,146.88,292,
STAPLER LINEAR PROX,90001540,CDM,270,RC,,,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
STAPLER PREMIUM CEEA 28,90001541,CDM,270,RC,,,outpatient,,,3600,2700,,2880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1980,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1448.64,2880,
STAPLER PREMIUN  CEEA 31,90001542,CDM,270,RC,,,outpatient,,,3600,2700,,2880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1980,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2700,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1448.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1448.64,2880,
CHOLECYSTECTOMY - OPEN,400013,CDM,360,RC,47600,HCPCS,outpatient,,,9632,7224,,7705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3875.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,8300.68,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9632,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5297.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7705.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7224,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7224,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7224,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7224,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9632,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9632,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9632,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,3875.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3875.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9632,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7705.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9632,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7224,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7705.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7705.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3875.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9632,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9632,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9632,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,7705.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9632,
MON LNQ11 REVEAL LINQ FAMILY DEVICE,5890108,CDM,278,RC,C1764,HCPCS,both,,,9690,7267.5,,7752,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3899.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5329.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4845,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7267.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7267.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7267.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7267.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3899.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3899.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6783,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7267.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3899.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3899.26,7752,
PACEMAKER ESSENTIO MRI DR IS-1,5890010,CDM,275,RC,C1785,HCPCS,outpatient,,,10100,7575,,8080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5555,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7070,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8080,
STENT CORONARY 3.0 1007848-18,90001560,CDM,270,RC,,,outpatient,,,1866,1399.5,,1492.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,933,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1026.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1399.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1492.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,750.88,1492.8,
ESSENTIO MRI DR (INGEVITY) L111,5890054,CDM,275,RC,C1785,HCPCS,outpatient,,,10100,7575,,8080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5555,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7070,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4064.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,8080,
STENT ELUTING CORONARY 1009541-12,90001568,CDM,270,RC,,,outpatient,,,4950,3712.5,,3960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2722.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1991.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1991.88,3960,
CATHETER PLACEMENT CAROTID ARTERY,5800200,CDM,480,RC,36224,HCPCS,outpatient,,,10179,7634.25,,8143.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4096.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11566.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,11566.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,11566.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5598.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4432.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4096.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4096.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7634.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4096.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7596.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4747.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7121.51,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,11566.45,
DCA 1ST SINGLE VESSEL,5800058,CDM,480,RC,92924,HCPCS,outpatient,,,11148,8361,,8918.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24440.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24440.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24440.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6131.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15688.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,24440.37,
STENT PROMUS EVEROLIMUS,90001578,CDM,270,RC,,,outpatient,,,6500,4875,,5200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2615.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3575,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2615.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2615.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2615.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5200,
STERI-STRIP 1/4 X3,90001593,CDM,270,RC,,,outpatient,,,4.5,3.38,,3.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.48,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.81,3.6,
STYLETTE INTUBATING ADULT 15FR BOUGIE,90001613,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SUCTION IRRIGATION SET,90001615,CDM,270,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
DO NOT USE SUCTION VALVE MAJ-209,90001616,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DO NOT USE SURGICEL HEMOSTAT 4X8 JJ1952,90001621,CDM,270,RC,,,outpatient,,,64,48,,51.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,25.75,51.2,
SURGICEL HEMOSTAT 4X8 JJ1952,90001622,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
SUTURE VICRYL 1,90001626,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SUTURE 3.0 PROLENE,90001644,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
SUTURE ETHIBOND XTR GR BR CX41D,90001657,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SUTURE MONOCRYL 4.0,90001668,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SUTURE SILK TIE18,90001673,CDM,270,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
SUTURE SILK 0 BLACK,90001675,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SUTURE SILK 4-0 BLACK,90001682,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
SUTURE SILK TIE 2-0,90001684,CDM,270,RC,,,outpatient,,,4,3,,3.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.61,3.2,
SUTURE STEEL 5,90001685,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
SUTURE VICRYL 1 TIES,90001686,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
SUTURE VICRYL 0 J906G,90001687,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
SUTURE VICRYL 0 J946H,90001689,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
SYRINGE W/NEEDLE 3ML HYPODERMIC 25G 5/8,90001722,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SYRINGE DUAL QUAD/SPIKE,90001728,CDM,270,RC,,,outpatient,,,28.42,21.32,,22.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.63,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.44,22.74,
TEGADERM 15X20,90001746,CDM,270,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
TEGADERM 8  X 12,90001747,CDM,270,RC,,,outpatient,,,8.5,6.38,,6.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.42,6.8,
TELFA 3X4 KEND2132,90001749,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
TELFA DRESSING 8X3 KEND1238,90001750,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
TENSOPLAST 3' FOR SURGERY,90001752,CDM,270,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
TRANSDUCER COVER (SURGERY/CATH LAB),90001790,CDM,270,RC,,,outpatient,,,25.5,19.13,,20.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.03,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.26,20.4,
TRAP SUCTION POLYP STERILE,90001793,CDM,270,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
TREK CORONARY DILATATION,90001794,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
TROCAR 11MM STANDARD SEPE C0667A,90001798,CDM,270,RC,,,outpatient,,,111,83.25,,88.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,44.67,88.8,
TROCAR BALLOON,90001800,CDM,270,RC,,,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
TROCAR ENDO CLOSE 173022,90001803,CDM,270,RC,,,outpatient,,,228,171,,182.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,91.75,182.4,
TROCAR THORACOPORT,90001805,CDM,270,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
TROCAR W/SHIELD FB OBTURA,90001807,CDM,270,RC,,,outpatient,,,86,64.5,,68.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.61,68.8,
TUBE BRONCHIAL PVC 37,90001811,CDM,270,RC,,,outpatient,,,206,154.5,,164.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,103,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.89,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,82.89,164.8,
TUBE ENDO 3.0,90001815,CDM,270,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
TUBE ENDO 3.5MM,90001816,CDM,270,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
TUBE ENDO 4.0,90001817,CDM,270,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
TUBE ENDO 4.5,90001818,CDM,270,RC,,,outpatient,,,15.5,11.63,,12.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.53,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.24,12.4,
TUBING HUDSON VENTILATOR CIRCUIT,90001832,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
TUBING INSUFFLATION,90001833,CDM,270,RC,,,outpatient,,,26,19.5,,20.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.46,20.8,
"TUBING, O2 CRUSH RESIST. 25 FT",90001835,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VAC TUBE 5 ML GOLD SST,90001848,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VACUTAINER BUTTERFLY 23G,90001851,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VAGINAL SPECULA LARGE,90001852,CDM,270,RC,,,outpatient,,,4.48,3.36,,3.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.46,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.8,3.58,
VAGINAL SPECULA SMALL,90001854,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VANILLA SMOOTHIE,90001857,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
MULTIHANCE 5ML,90001864,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
VISION  BIPAP CIRCUITS,90001875,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
WIPES BABY,90001901,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DCA ADD VESSEL,5800059,CDM,480,RC,92925,HCPCS,outpatient,,,11148,8361,,8918.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24440.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24440.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24440.37,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,5574,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6131.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8361,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4485.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8918.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,24440.37,
WOUND VAC <50CM RENTAL UNIT,90001907,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
DO NOT USE WRIST & FOREARM SPLINT L/L,90001912,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
DO NOT USE WRIST & FOREARM SPLINT L/M,90001913,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
DO NOT USE WOUND VAC <50CM,90001914,CDM,270,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
XIENCE V CORONARY STENT SYSTEM,90001919,CDM,278,RC,,,both,,,3300,2475,,2640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1815,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2310,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2475,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1327.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1327.92,2640,
CATHETER SYS NEXIVA 22G,90001930,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
SUCTION SIGMOIDOSCOPIC,90001931,CDM,270,RC,,,outpatient,,,13.5,10.13,,10.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.43,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.43,10.8,
GLOVES PROTEXIS 6.0,90001932,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
STENT PLACED 1ST VESSEL,5800181,CDM,480,RC,37205,HCPCS,outpatient,,,11278,8458.5,,9022.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5639,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5639,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5639,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5639,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6202.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8458.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4538.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9022.4,
CIRCUIT DISPOSABLE WITH FILTER,90001941,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
FINGERPROBE SPO2 NELLCOR,90002001,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
EXTENSION SET 1 SMARTSITE,90002006,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CATHETER CHOLANGIOGRAPHY,90002998,CDM,270,RC,,,outpatient,,,324,243,,259.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,162,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,130.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.38,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,130.38,259.2,
DO NOT USE SLEEVE VENODYNE XL,90002999,CDM,270,RC,,,outpatient,,,65,48.75,,52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.16,52,
PUNCH BIOPSY DISP 5MM,90003003,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
PUNCH BIOPSY DISP 6MM,90003004,CDM,270,RC,,,outpatient,,,6.5,4.88,,5.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.62,5.2,
SPONGE RONDIAC,90003010,CDM,270,RC,,,outpatient,,,2.5,1.88,,2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.38,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.01,2,
STENT COR 1ST VESSEL,5800178,CDM,480,RC,92920,HCPCS,outpatient,,,11338,8503.5,,9070.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4562.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12817.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12817.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12817.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6235.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9070.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4498.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4562.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4562.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9070.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8503.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9070.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9070.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4562.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7708.07,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,4817.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,9070.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12817.44,
MASK WHITE SENSITIVE FOR SURGERY,90003226,CDM,270,RC,,,outpatient,,,3.5,2.63,,2.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.93,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.41,2.8,
VACUTAINER ONE-USE HOLDER,90003455,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
LMA SIZE 3 DISPOSABLE,90004013,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
LMA SIZE 5.0 DISPOSABLE,90004014,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER GUIDING XB3.5,90005464,CDM,270,RC,,,outpatient,,,130,97.5,,104,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,52.31,104,
MESH VERITAS COLLAGEN MATRIX 10CMX16CM,490060,CDM,270,RC,C9354,HCPCS,outpatient,,,11474.78,8606.09,,9179.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4617.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5737.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5737.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5737.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5737.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6311.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9179.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8606.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8606.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8606.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8606.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4617.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4617.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9179.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8606.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9179.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9179.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4617.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9179.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,9179.82,
ATHRECTOMY ILLIAC,5800027,CDM,278,RC,0238T,HCPCS,both,,,12000,9000,,9600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4828.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20347.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20347.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,20347.51,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6600,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4828.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4828.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9000,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4828.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25387.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,9600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4828.8,25387.55,
PACER SINGLE GENERATOR ONLY,5800121,CDM,480,RC,33212,HCPCS,outpatient,,,12844,9633,,10275.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5168.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10451.85,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,10451.85,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,10451.85,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7064.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5168.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5168.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9633,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5168.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12064.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12064.12,
SHEATH INTRODUCING RCB,90005470,CDM,270,RC,,,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,70.4,
CATHETER AVANTI 4 FR,90005471,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
MULTIPACK CUSTOMIZED F5 CP0207,90005488,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
TISSUE FUSION OPEN INSTRUMENT,90005495,CDM,270,RC,,,outpatient,,,1950,1462.5,,1560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1072.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1462.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,784.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,784.68,1560,
LIGASURE BLUNT TIP LAP SEALER LF1637,90005496,CDM,270,RC,,,outpatient,,,2000,1500,,1600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,804.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,804.8,1600,
SUTURE CHROMIC 0,90005498,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
CANNULA PED. NASAL W/TUBING,90005500,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
TRACH SWIVEL WITH S/PORT,90005509,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
ENDO TRACH TUBE HOLDER,90005510,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BIOPSY COAXIAL C1810A,90005513,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
BIOPSY COAXIAL C1816A,90005514,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
DISPOSABLE CORE BIOPSY MC1810,90005515,CDM,270,RC,,,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
DISPOSABLE CORE BIOPSY MC1816,90005516,CDM,270,RC,,,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
CURETTE DISPOSABLE EAR LOOP WHITE,90005528,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CATHETER CORONARY JL5 534-522T,90005541,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER RIGHT CORONARY JR4 534-521T,90005542,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER RIGHT CORONARY JR5 534-523T,90005543,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER MULTIPURPOSE MPAZ 534-542T,90005544,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER AMPLATZ AR2 MOD 534-543T,90005545,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER AMPLATZ AL1 534-545T,90005546,CDM,270,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
CATHETER INTERNAL MAMMARY 534-560T,90005547,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER CORONARY BYPASS RCB 534-570T,90005548,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER CORONARY BYPASS LCB 534-572T,90005549,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CATHETER VENTRICULAR PIGTAIL 534-552S,90005550,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CARTRIDGE HP 564XL - INFECTION CONTROL,90005563,CDM,130,RC,,,inpatient,,,,,,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,2737.25,
CATHETER ANGIOGRAPHIC 565354RBI,90005568,CDM,270,RC,,,outpatient,,,34,25.5,,27.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.68,27.2,
STERI-STRIPS 1/4X4,90005572,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DRAINAGE BAG FOR LOCKING PIGTAIL,90005579,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
SHEATH SUPER 16035-06B,90005580,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
SHEATH SUPER 16034-04B,90005581,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
MICROPUNCTURE PEDAL 4 FR,90005582,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
MICROPUNCTURE PEDAL 5 FR,90005583,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
CATHETER CXI SUPPORT,90005584,CDM,270,RC,,,outpatient,,,585,438.75,,468,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,235.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,292.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,321.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,235.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,235.4,468,
DON'T USE EVACUATED CONTAINER,90005586,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
OXYGEN FLOWMETER 1/2-15 LPM,90005602,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
INSTANT HOT PACKS,90005606,CDM,270,RC,,,outpatient,,,3.65,2.74,,2.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.01,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.47,2.92,
CUTTER FLEX 60 ARTICULATING EC60A,90005617,CDM,270,RC,,,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,600,
STAPLER RELOAD ENDOPATH GRN 4.1 MM,90005618,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
STAPLER RELOAD ENDOPATH BLUE 3.5 MM,90005619,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
"HYDROGEL, SKINTEGRITY, 1 OZ",90005623,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
STAPLER RELOAD ENDOPATH WHT 12 MM,90005628,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
DO NOT USE ETHICON SKIN STAPLES,90005642,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
PORT CLOSURE SYSTEM,90005650,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
MYELOGRAM TRAY WTR SOL,90005660,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
STENT EACH ADD VESSEL,5800179,CDM,480,RC,92921,HCPCS,outpatient,,,13338,10003.5,,10670.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5367.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12817.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12817.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,12817.44,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,6669,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7335.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10003.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10003.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10003.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10003.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5367.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5367.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10003.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5367.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,12817.44,
PACER DUAL GENERATOR ONLY,5800114,CDM,480,RC,33213,HCPCS,outpatient,,,13920,10440,,11136,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5601.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,12980.88,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7656,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10440,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10440,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10440,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10440,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5601.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5601.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10440,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5601.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,15265.35,
DISPOSABLE CORE BIOPSY MC1410,90005682,CDM,270,RC,,,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
BIOPSY COAXIAL C1410A,90005683,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
BREAST LOC WIRE LW0037,90005684,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
BREAST LOC WIRE LW0057,90005685,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
DISPOSABLE CORE BIOPSY MC1610,90005686,CDM,270,RC,,,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
BIOPSY COAXIAL C1610A,90005687,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
DISPOSABLE CORE BIOPSY MC1616,90005688,CDM,270,RC,,,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
BIOPSY COAXIAL C1616A,90005689,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
BREAST LOC WIRE LW0077,90005690,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
BREAST LOC WIRE LW0107,90005691,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
BREAST LOC WIRE LW0137,90005692,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
DISPOSABLE CORE BIOPSY MC1416,90005693,CDM,270,RC,,,outpatient,,,168,126,,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,67.6,134.4,
BIOPSY COAXIAL  C1416A,90005694,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
CT GUIDELINES #217,90005698,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
BIPOLAR PACING KIT STRAIGHT 401762,90005699,CDM,270,RC,,,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,176,
BIPOLAR PACING KIT CURVED 401764,90005700,CDM,270,RC,,,outpatient,,,220,165,,176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,88.53,176,
PTA FEM/POP/W ATHRECTOMY,5800133,CDM,480,RC,37225,HCPCS,outpatient,,,14000,10500,,11200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7700,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15688.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,25568.45,
DURA ACTIVE LEADS BNP035851/7120Q/58,90005705,CDM,270,RC,,,outpatient,,,9400,7050,,7520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3782.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5170,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3782.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3782.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7050,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3782.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7520,
SUTURE VICRYL 0 18IN VIOLET ENDOLOOP,90005719,CDM,270,RC,,,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
DO NOT ORDER UTERINE MANIPULATOR HRS-KRO,90005736,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
FLEXIMA LOCKING PIGTAIL CATHETER,90005738,CDM,270,RC,,,outpatient,,,443.55,332.66,,354.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,243.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,178.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,178.48,354.84,
BUTTERFLY NEEDLES,90005761,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
VASCULAR ACCESS PACK POWER DRIVER,90005762,CDM,270,RC,,,outpatient,,,79.9,59.93,,63.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.15,63.92,
STABILIZER IFU 8034 POWER DRIVER,90005763,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
NEEDLE 15MM POWER DRIVER EZ I O,90005764,CDM,270,RC,,,outpatient,,,273.2,204.9,,218.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,109.94,218.56,
25 MM NEEDLE POWER DRIVER NEEDLE,90005765,CDM,270,RC,,,outpatient,,,270,202.5,,216,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.65,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,108.65,216,
45 MM NEEDLE POWER DRIVER,90005766,CDM,270,RC,,,outpatient,,,273.2,204.9,,218.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.26,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.94,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,109.94,218.56,
ACCUTEST HCG URINE,90005779,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SPINAL NEEDLE 18GX3.5 X-RAY,90005787,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SPINAL NEEDLE 20GX3.5 X-RAY,90005788,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SPINAL NEEDLE 22G X 3.5,90005789,CDM,270,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
DONT USE SLEEVE XL LINED COMPRESSION,90005806,CDM,270,RC,,,outpatient,,,225,168.75,,180,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,90.54,180,
CRICOTHYROTOMY KIT EMERGENCY,90005810,CDM,270,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
PARACENTESIS TRAY,90005822,CDM,270,RC,,,outpatient,,,200,150,,160,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,80.48,160,
THORACENTESIS TRAY 8 FR,90005823,CDM,270,RC,,,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
PACEMAKER SECURA,90006000,CDM,270,RC,,,outpatient,,,39000,29250,,31200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15693.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21450,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15693.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15693.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15693.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,31200,
BIPAP PLUS SET W/HUMIDIFIER SET-UP,90006110,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
SHEATH SUPER 16035-05B,90006111,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
CATHETER HOCKEY STICK,90006112,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER AMPLATZ LEFT CORONARY 6FR,90006113,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER AMPLATZ RIGHT CORONARY 6FR,90006114,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER JUDKINS RIGHT CORONARY 6FR,90006115,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER JUDKINS SIDE HOLE JR4SH,90006116,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER JUDKINS RIGHT CORONARY JR3.5,90006117,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER GUIDING XBRCA,90006118,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER GUIDING XBRCASH 6FR,90006119,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
CATHETER VISTA BRITE GUIDING,90006120,CDM,270,RC,,,outpatient,,,132,99,,105.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,53.12,105.6,
SANDBAG - FEMORAL 7 W X 9 L,90006124,CDM,270,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
SANDBAG - FEMORAL 5 W X 12 L,90006125,CDM,270,RC,,,outpatient,,,108,81,,86.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.46,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,43.46,86.4,
LMA SZ 1.5,90006127,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
CIRCUIT VENTILATOR SINGLE LIMB UNIVERSAL,90006128,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
WOUND VAC DAILY USE,90006137,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
CAP NEWBORN BABY,90006138,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
FOOTPRINTER - NEWBORN,90006139,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
OB PACK - ER,90006140,CDM,270,RC,,,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.25,84,
PESSARY GELLHORN 3 (PESSARY ONLY),90006148,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
INTRODUCER KIT TEAR AWAY 9FR GAULT,90006150,CDM,270,RC,,,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.09,97.6,
CASSETTE ULTA VERALINK (FOR KCI),90006151,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
"DRESSING ULTA VERAFLO, MEDIUM (KCI)",90006152,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
SST YELLOW TOP 8 ML (START),90006154,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
RED/BLACK TOP TUBE 6 ML (NE/START),90006155,CDM,270,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
DO NOT USE MICRO INTRODUCER KIT,90006159,CDM,270,RC,,,outpatient,,,399,299.25,,319.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,199.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.45,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.56,319.2,
MASK VENTURI ADULT STYLE MASK,90006174,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
ENDOSTITCH SUTURING DEVICE #173016,90006175,CDM,270,RC,,,outpatient,,,900,675,,720,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,362.16,720,
SOFSILK ENDOSTITCH LOADING DEVICE#170002,90006176,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
NOVASURE HH NS2000,90006179,CDM,270,RC,,,outpatient,,,2300,1725,,1840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1265,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1725,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,925.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,925.52,1840,
GUIDING CATHETER XBC 3.5,90006199,CDM,270,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
GUIDING CATHETER XBLAD 3.5,90006200,CDM,270,RC,,,outpatient,,,120,90,,96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.29,96,
E Z GAS 2 EFFERVESENT GRANULES,90006203,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
CANISTER HOLDER SUCTION 65652-516,90006206,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
CATHETER 4FR 100 CM 538-460,90006209,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
ENDOPATH EXCEL TIP,90006218,CDM,270,RC,,,outpatient,,,375,281.25,,300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,150.9,300,
CATHETER GUIDING 670-004-00,90006220,CDM,270,RC,,,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,70.4,
3ML SYRINGE W/BLUNT TIP NEEDLE 18G,90006222,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
OS FINDER (NE CLINIC),90006231,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
FUNDUS DILATOR (NE CLINIC),90006232,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
FILTER ASTRAGUARD W/KUSHION KLIP,90006240,CDM,270,RC,,,outpatient,,,6,4.5,,4.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.41,4.8,
AUXILLARY CHANNEL WATER TUBE,90006247,CDM,270,RC,,,outpatient,,,31.14,23.36,,24.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.53,24.91,
PTA/ FEM/POP W/STENT,5800150,CDM,480,RC,37226,HCPCS,outpatient,,,14000,10500,,11200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7700,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5633.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15688.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,25568.45,
T-CONNECTOR FOR RESP.,90006260,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
ETCO2 SAMPLE LINE,90006262,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
DISPOSABLE CORE BIOPSY GUN MC2016,90006268,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
BIOPSY COAXIAL C2016A,90006269,CDM,270,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
KIT BALLARD SUCTION 2205,90006272,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
GELFOAM SZ 100,90006273,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
PTA TIBIO/PERONL W/ ATHRE,5800143,CDM,480,RC,37229,HCPCS,outpatient,,,15000,11250,,12000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8250,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25387.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,25568.45,
PTA TIBIO/PERONL W/ATHRE EA ADD,5800144,CDM,480,RC,37233,HCPCS,outpatient,,,15000,11250,,12000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8250,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,25568.45,
CANNULA NONE FLAIR TIP RESP.,90006286,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
KIT COAXIAL MINI ACCESS S-MAK501N,90006296,CDM,101,RC,,,inpatient,,,72,54,,50.4,70,,,percent of total billed charges,70% of billed charges for inpatient setting,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,63.59,88.32,,,percent of total billed charges,88.32% of billed charges for inpatient setting,63.59,88.32,,,percent of total billed charges,88.32% of billed charges for inpatient setting,63.59,88.32,,,percent of total billed charges,88.32% of billed charges for inpatient setting,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",57.6,80,,,percent of total billed charges,80% of billed charges for inpatient setting,54,75,,,percent of total billed charges,75% of billed charges for inpatient setting,54,75,,,percent of total billed charges,75% of billed charges for inpatient setting,54,75,,,percent of total billed charges,75% of billed charges for inpatient setting,54,75,,,percent of total billed charges,75% of billed charges for inpatient setting,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,57.6,80,,,percent of total billed charges,80% of billed charges for inpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,50.4,2737.25,
CATHETER GUIDING 3.0 SIDEHOLE,90006304,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
CATHETER GUIDING 3.5 SIDEHOLE,90006306,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
CATHETER GUIDING 4.0 SIDEHOLE,90006308,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
CATHETER GUIDING 4.0 W/O SIDEHOLE,90006309,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
CATHETER GUIDING 4.5 SIDEHOLE,90006310,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
CATHETER GUIDING 4.5 W/O SIDEHOLE,90006311,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
CATHETER GUIDING SBSRCA SIDEHOLE,90006312,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
CATHETER GUIDING SBSRCA W/O SIDEHOLE,90006313,CDM,270,RC,,,outpatient,,,114,85.5,,91.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.87,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,45.87,91.2,
SILS PORT W/CANNULA,90006316,CDM,270,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
SILS CLINCHER,90006317,CDM,270,RC,,,outpatient,,,861,645.75,,688.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,346.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,430.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,430.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,430.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,430.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,473.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,688.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,346.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,688.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,688.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.47,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,346.47,688.8,
VIPERSLIDE 100 ML BAG,90006319,CDM,278,RC,,,both,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,27,
STENT SYSTEM CORONARY 1007849-23,90006325,CDM,270,RC,,,outpatient,,,2800,2100,,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1540,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2100,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1126.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1126.72,2240,
PTA TIBIO/PERONL W/STENT,5800145,CDM,480,RC,37230,HCPCS,outpatient,,,15000,11250,,12000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,25568.45,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8250,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25387.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,25568.45,
CATHETER 4 FR INF. MPA2  538-442,90006327,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
COVER MATTRESS ZIPPERED,90006328,CDM,100,RC,,,inpatient,,,,,,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,2737.25,
GLIDESHEATH SLENDER 6FR,90006361,CDM,270,RC,,,outpatient,,,210,157.5,,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,84.5,168,
GLIDEWIRE 1.5 BABY J,90006362,CDM,270,RC,,,outpatient,,,198,148.5,,158.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,79.68,158.4,
BAND STANDARD TR W/INFLATOR,90006363,CDM,270,RC,,,outpatient,,,165,123.75,,132,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.4,132,
GLIDE CATHETER 4 FR,90006364,CDM,270,RC,,,outpatient,,,214.5,160.88,,171.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,107.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.98,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,86.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.31,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,86.31,171.6,
SYSTEM COMPRESSAR STRONGARM,90006368,CDM,270,RC,,,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
CELOX PATCH VASCULAR HEMOSTATIS,90006369,CDM,270,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
DISCS LARGE 2' SUPERCOMFORT,90006370,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
BANANA SMOOTHIE SCAN C,90006372,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
BREEZA,90006373,CDM,270,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
STENT CORONARY EVEROLIMUS-ELUTING,90006375,CDM,270,RC,,,outpatient,,,4500,3375,,3600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1810.8,3600,
STENT CORONARY EVEROLIMUS-ELUTING,90006376,CDM,270,RC,,,outpatient,,,4500,3375,,3600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1810.8,3600,
STENT CORONARY EVEROLIMUS-ELUTING,90006377,CDM,270,RC,,,outpatient,,,4500,3375,,3600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2475,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1810.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1810.8,3600,
ADULT XL SP02 SENSOR,90006389,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
WIRE GUIDE SAVARY-GILLIARD,90006412,CDM,270,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
EOVIST MULTIHANCE MRI CONTRAST 10ML,90006416,CDM,270,RC,,,outpatient,,,490,367.5,,392,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,269.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,197.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,197.18,392,
TOURNIQUET CUFF 18  DISPOSABLE,90006419,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
DILATOR BALLOON 3 STAGE ESOPHAGEAL,90006421,CDM,270,RC,,,outpatient,,,544,408,,435.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,299.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,218.91,435.2,
DILATOR BALLOON 15-16.5-18,90006422,CDM,270,RC,,,outpatient,,,544,408,,435.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,299.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,218.91,435.2,
SYRINGE STERILE INTEGRATED INFLATION,90006423,CDM,270,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
POWER GLIDE MID-LINE CATHETER,90006424,CDM,270,RC,,,outpatient,,,123,92.25,,98.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.5,98.4,
BIPOLAR INSERT KLEPPINGER 32 CM,90006428,CDM,270,RC,,,outpatient,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,440,
FENN BIPOLAR INSERT W/WIRE,90006429,CDM,270,RC,,,outpatient,,,790,592.5,,632,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,317.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,434.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,317.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,592.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,317.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,317.9,632,
CABLE BIPOLAR FOR GENERATOR,90006430,CDM,270,RC,,,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
BONE CUTTING BIOPSY NEEDLE,90006437,CDM,270,RC,,,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
GUIDEWIRE EXTRA SUPPORT,90006451,CDM,270,RC,,,outpatient,,,164.8,123.6,,131.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.32,131.84,
COVERALL BLUE XL,90006462,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SURGIMESH T613-85,90006488,CDM,270,RC,,,outpatient,,,500,375,,400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,201.2,400,
NEEDLE ILLINOIS BONE MARROW,90006489,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
TRAY BONE MARROW JAMSHIDI,90006490,CDM,270,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
PEDIATRIC CO2 DETECTOR,90006494,CDM,270,RC,,,outpatient,,,28,21,,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.27,22.4,
TOWEL OR BLUE 17 X 24 DISP,90006510,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
FACE MASK CPAP WITH STRAP LARGE,90006520,CDM,270,RC,,,outpatient,,,51.66,38.75,,41.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.79,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.79,41.33,
FACE MASK CPAP STRAP MEDUIM,90006521,CDM,270,RC,,,outpatient,,,52,39,,41.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.92,41.6,
BIOPSY SYSTEM COAXIAL TEMNO EVOLUTION,90006523,CDM,270,RC,,,outpatient,,,122,91.5,,97.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.09,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,49.09,97.6,
MARKER BREAST TISSUE ULTRA CLIP,90006524,CDM,270,RC,,,outpatient,,,414,310.5,,331.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,207,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,227.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,166.59,331.2,
SURGIMESH WN T613-8S/F10695A,90006529,CDM,270,RC,,,outpatient,,,750,562.5,,600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,301.8,600,
REMOVAL & REPLACE PM GEN,5800156,CDM,480,RC,33227,HCPCS,outpatient,,,15000,11250,,12000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21018.2,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,21018.2,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,21018.2,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8250,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7040.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6036,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12064.12,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,7540.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,21018.2,
CORONARY STENT SYSTEM 3.00X12MM,90006544,CDM,270,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
DRUG STENT 1ST VESS,5800062,CDM,480,RC,C9600,HCPCS,outpatient,,,15086,11314.5,,12068.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24733.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24733.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24733.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8297.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9155.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15688.84,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9805.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,24733.49,
DRUG STENT EACH ADD,5800063,CDM,480,RC,C9601,HCPCS,outpatient,,,15086,11314.5,,12068.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24733.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24733.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,24733.49,135,,,fee schedule,135% BCBS fee schedule for outpatient setting,7543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8297.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11314.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12068.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6070.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,24733.49,
PACER SINGLE CHAMBER SYS ATRIAL,5800119,CDM,480,RC,33206,HCPCS,outpatient,,,15496,11622,,12396.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13562.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,13562.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,13562.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8522.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,15265.35,
CATHETER 6F .072 XB 4 100CM 67205600,90006558,CDM,270,RC,,,outpatient,,,87,65.25,,69.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.01,69.6,
PACER SINGLE CHAMBER SYS VENTRICULAR,5800120,CDM,480,RC,33207,HCPCS,outpatient,,,15496,11622,,12396.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13562.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,13562.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,13562.38,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8522.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,11622,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6235.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,15265.35,
PACER DUAL CHAMBER SYSTEM,5800113,CDM,480,RC,33208,HCPCS,outpatient,,,17838,13378.5,,14270.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15856.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15856.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15856.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9810.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,15856.48,
PLEURX CATHETER DRAINAGE KIT,90006575,CDM,270,RC,,,outpatient,,,128.62,96.47,,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,64.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.74,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,51.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,51.76,102.9,
MASK NIV FULL FACE SMALL ADULT BITRAC,90006576,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
UPGRADE FROM SINGLE TO DUAL CHAMBER,5800192,CDM,480,RC,33214,HCPCS,outpatient,,,17838,13378.5,,14270.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15856.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15856.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15856.48,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,9810.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13378.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7178.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,15856.48,
SUTURE 4.0 PROLENE,90006599,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
PTA FEM/POP W/STENT/ATHR,5800132,CDM,480,RC,37227,HCPCS,outpatient,,,25000,18750,,20000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44281.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,44281.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,44281.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13750,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25387.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,44281.28,
CORONARY STENT SYSTEM EVEROLIMUS,90006601,CDM,270,RC,,,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2080,
MEDIPORE 4'' TAPE,90006607,CDM,100,RC,,,inpatient,,,,,,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,2737.25,
DO NOT ORDER BLANKET UPPER 5030870,90006608,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
LMA SIZE 4 DISPOSABLE,90006615,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
CORONARY STENT EVERLIMOUS 1125350-12,90006622,CDM,270,RC,,,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2080,
SUTURE VICRYL 18  J727D,90006626,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
POWERLOC NEEDLE 20 X 1,90006627,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
DISPOSABLE BIOPSY CORE GUN MC2010,90006628,CDM,270,RC,,,outpatient,,,105,78.75,,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,42.25,84,
BIOPSY NEEDLE TROCAR C2010A,90006629,CDM,270,RC,,,outpatient,,,51,38.25,,40.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.52,40.8,
STENT XIENCE EVEROLIMUS ELUTING,90006633,CDM,270,RC,,,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2080,
STENT XIENCE EVEROLIMUS ELUTING,90006634,CDM,270,RC,,,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2080,
STENT XIENCE EVEROLIMUS ELUTING,90006635,CDM,270,RC,,,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2080,
MARKER WIRE H74934949050,90006636,CDM,270,RC,,,outpatient,,,164.8,123.6,,131.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,66.32,131.84,
CATHETER DILATATION PTCA,90006637,CDM,270,RC,,,outpatient,,,510,382.5,,408,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,205.22,408,
TELEMETRY UNIT TRANSMITTER LX-7120,90006641,CDM,270,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
CLEARIFY VISUALIZATION SYSTEM,90006645,CDM,270,RC,,,outpatient,,,100,75,,80,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,40.24,80,
CORONARY STENT SYSTEM 1125400-18,90006648,CDM,270,RC,,,outpatient,,,2600,1950,,2080,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1430,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1046.24,2080,
CORONARY STENT SYSTEM 1007847-18,90006649,CDM,270,RC,,,outpatient,,,1900,1425,,1520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1045,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,764.56,1520,
FORCEP ADSON STR 7.25,90006660,CDM,111,RC,,,inpatient,,,,,,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,2737.25,
CATHETER CORONARY DILATATION NC TREK,90006665,CDM,270,RC,,,outpatient,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.03,344,
CATHETER CORONARY DILATATION TREK,90006669,CDM,270,RC,,,outpatient,,,430,322.5,,344,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,173.03,344,
DISPOSABLE CORE BIOPSY KIT,90006670,CDM,270,RC,,,outpatient,,,450,337.5,,360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,181.08,360,
PTA TIBIO/PERONL W/STENT/ ATHRE,5800147,CDM,480,RC,37231,HCPCS,outpatient,,,25000,18750,,20000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44281.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,44281.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,44281.28,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13750,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,14815.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10060,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25387.55,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,15867.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,44281.28,
GUIDEWIRE 6F SUPER SHEATH,90006672,CDM,270,RC,,,outpatient,,,350,262.5,,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,140.84,280,
STENT CORONARY SYSTEM 2.25 X 12MM,90006674,CDM,270,RC,,,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,2400,
STENT CORONARY SYSTEM,90006675,CDM,270,RC,,,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,2400,
CATHETER DILATATION PTCA,90006676,CDM,270,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
STENT CORONARY MINI VISION RX BARE METAL,90006684,CDM,270,RC,,,outpatient,,,1900,1425,,1520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1045,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1425,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,764.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,764.56,1520,
FLEXIWRAP ADULT SENSOR WRAP,90006685,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
ELECTRODE DISP CENTER SNAP SLEEP STUDY,90006688,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
TUBE VACUETTE LITHIUM HEPARIN/GREEN 9ML,90006690,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
MICROTAINER W/MICROGUARD PST,90006691,CDM,270,RC,,,outpatient,,,84,63,,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,33.8,67.2,
MICROTAINER W/MICROGUARD SST GOLD,90006692,CDM,270,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
SUTURE VICRYL 0 UND  JJ41G,90006695,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
SUTURE VICRYL 3-0 UND  J864D,90006696,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
SUTURE MONOVICRYL 4-0 UND  MCP494G,90006697,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
APPLICATOR CHLORAPREP,90006699,CDM,360,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
NEEDLE PRECISION GLIDE HYPO. 21G X2,90006704,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
COLORECTAL KIT 3707,90006707,CDM,270,RC,,,outpatient,,,336,252,,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,184.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,135.21,268.8,
PORT POWER 8 FR,90006712,CDM,270,RC,,,outpatient,,,916,687,,732.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,368.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,458,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,458,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,458,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,458,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,368.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,687,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,368.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,368.6,732.8,
SUTURE 3-0 VICRYL PS-2 J427,90006715,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
PROMUS PERMIER STENT,90006718,CDM,271,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
SUTURE VICRYL J270H,90006722,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
"TUBE, JEJUNAL 14FR 7-10ML",90006723,CDM,270,RC,,,outpatient,,,320,240,,256,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.77,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,128.77,256,
CATHETER GUIDING 670-002-00,90006732,CDM,270,RC,,,outpatient,,,88,66,,70.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.41,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,35.41,70.4,
STENT NXL27533US,90006733,CDM,270,RC,,,outpatient,,,850,637.5,,680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,467.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,637.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,342.04,680,
GENERATOR HV #CD1411-36C ELLIPSE VR_ICD_,5890002,CDM,275,RC,C1722,HCPCS,outpatient,,,25500,19125,,20400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10261.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14025,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10261.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10261.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17850,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10261.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,20400,
CORONARY STENT,90006743,CDM,270,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
SENSOR O2 FOR FUKUDU,90006756,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
CORONARY STENT NXL35012US,90006768,CDM,270,RC,,,outpatient,,,1000,750,,800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,402.4,800,
CATHETER MONORAIL PTCA DILATATION,90006769,CDM,270,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
CORONARY STENT SYSTEM EVEROLIMUS,90006770,CDM,270,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
CANNULA NEONATAL,90006784,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
CATHETER F5 INF. PIGTAIL,90006785,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
T-TUBE DEAVER 8FR,90006786,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 10 FR,90006787,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 12 FR,90006788,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 14 FR,90006789,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 16 FR,90006790,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 18 FR,90006791,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 20 FR,90006792,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 22 FR,90006793,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
T-TUBE DEAVER 24 FR,90006794,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
COBAN WRAP 4  X 5 YD,90006802,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
POUCH 1-PC OSTOMY 12  TRANS BARRIER 4,90006803,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
VISIA AF MRI S VR SYSTEM,5890117,CDM,275,RC,C1722,HCPCS,outpatient,,,27950,20962.5,,22360,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11247.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15372.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20962.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20962.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20962.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20962.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11247.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11247.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19565,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20962.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11247.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,22360,
SPONGE LAP 4 X 18,90006820,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
ICD-DR DDBC3D4 EVERA DEVICE,90006823,CDM,270,RC,,,outpatient,,,37040,27780,,29632,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14904.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20372,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27780,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27780,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27780,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27780,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14904.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14904.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27780,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29632,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14904.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,29632,
LEADS 6947M55 SPRINT FOR ICD-DR,90006824,CDM,270,RC,,,outpatient,,,9000,6750,,7200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4950,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6750,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3621.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7200,
LOOP RECORDER DEVICE,90006829,CDM,270,RC,,,outpatient,,,7000,5250,,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3850,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2816.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,5600,
DRESSING KALTOSTAT ROPE WOUND,90006830,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
PACEMAKER FORTIFYASSURA ICD UMRI PR SYST,5890011,CDM,275,RC,C1722,HCPCS,outpatient,,,29500,22125,,23600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16225,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20650,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,23600,
OPTICELL DRESSING W/AG+ 4 X 5,90006835,CDM,270,RC,,,outpatient,,,2100,1575,,1680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1155,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1575,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,845.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,845.04,1680,
OPTICELL DRESSING 2 X 2 W/AG+,90006836,CDM,270,RC,,,outpatient,,,12,9,,9.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.83,9.6,
PEDIATRIC IN/OUT KIT,90006844,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
PROFORE COMPRESSION LITE DRESSING,90006851,CDM,270,RC,,,outpatient,,,36,27,,28.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.49,28.8,
PURACOL DRESSING 2 X 2,90006852,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
ELECTRODE NEEDLE PRECISE 2.84,90006853,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SENSATRAC LG GRANUFOAM DRESSING,90006854,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
CATHETER MONORAIL PTCA DILATATION,90006855,CDM,270,RC,,,outpatient,,,600,450,,480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,241.44,480,
CORONARY STENT SYSTEM,90006856,CDM,270,RC,,,outpatient,,,950,712.5,,760,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,522.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,712.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,382.28,760,
SMOOTHIE VANILLA SILQ 256-1024,90006857,CDM,270,RC,,,outpatient,,,18,13.5,,14.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.24,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.24,14.4,
MONITOR SMART NEEDLE (GENERATOR) 058,90006879,CDM,270,RC,,,outpatient,,,1800,1350,,1440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,990,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,724.32,1440,
NEEDLE SMART BARE TIP 22 GA (058),90006880,CDM,270,RC,,,outpatient,,,250,187.5,,200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,100.6,200,
MICRO INTRODUCER KIT 5 FR (058),90006881,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
ESSENTIO DR IS-1 W/INGEVITY MRI IS-1,90006887,CDM,270,RC,,,outpatient,,,9500,7125,,7600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5225,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3822.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,7600,
PACEMAKER CD1411-36Q ELLIPSE VR_ICD_UMRI,5890039,CDM,275,RC,C1722,HCPCS,outpatient,,,29500,22125,,23600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16225,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20650,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,23600,
PACEMAKER ELLIPSE CD1411-36Q,90005704,CDM,278,RC,C1760,HCPCS,both,,,29500,22125,,23600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16225,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20650,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11870.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10000,23600,
TULOC BREAST LOC NEEDLE 5CM,90006898,CDM,270,RC,,,outpatient,,,125,93.75,,100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.3,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,50.3,100,
ECG & PHARMACOLOGY CD,90006904,CDM,270,RC,,,outpatient,,,67.5,50.63,,54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,27.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,27.16,54,
"MASK, ADULT NEB SYSTEM",90006905,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
BARIUM SULFATE HD SILQ SUSPENSION,90006922,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
GASTROGRAFIN 30ML,90006923,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
SUTURE CHROMIC GUT 1 (LIVER SUTURE),90006924,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
MESH PARIETENE MACROPOROUS,90006938,CDM,270,RC,,,outpatient,,,285,213.75,,228,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,114.68,228,
MESH SYMBOTEX 12CM,90006939,CDM,270,RC,,,outpatient,,,1750,1312.5,,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,704.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,875,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,875,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,875,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,875,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,962.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,704.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1312.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,704.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,704.2,1400,
MESH SYMBOTEX 15 CM,90006940,CDM,270,RC,,,outpatient,,,2400,1800,,1920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1320,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1800,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,965.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,965.76,1920,
STENT EVEROLIMUS ELUTING MONORAIL,90006943,CDM,270,RC,,,outpatient,,,3000,2250,,2400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1650,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1207.2,2400,
MESH SYMBOTEX  (SYM2015),90006946,CDM,270,RC,,,outpatient,,,2500,1875,,2000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1375,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1006,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1006,2000,
ABSORBATAC TACKER 30,90006947,CDM,270,RC,,,outpatient,,,1800,1350,,1440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,990,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1350,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,724.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,724.32,1440,
CURETTE ENDOMETRIAL SUCTION,90006948,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
TROCAR VERSAPORT 5MM (GYN),90006954,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
DO NOT ORDER TROCAR VERSAPORT 12MM (GYN),90006955,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
TISSUE SEALER ARTICULATING (GYN),90006960,CDM,270,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
DELINEATER ADVINCULA 3 CM (GYN),90006961,CDM,270,RC,,,outpatient,,,512,384,,409.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,281.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,206.03,409.6,
DELINEATER ADVINCULA 3.5 CM (GYN),90006962,CDM,270,RC,,,outpatient,,,475.49,356.62,,380.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,237.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,191.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,380.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,380.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,191.34,380.39,
DELINEATER ADVINCULA 4 CM (GYN),90006963,CDM,270,RC,,,outpatient,,,550,412.5,,440,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,302.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.32,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,221.32,440,
SUTURE V-LOC (VLOCL0315) GYN,90006964,CDM,270,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
DRAPE UNDER BUTTOCKS W/FLUID CONTROL POU,90006970,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
DRAPE LAVH TIBURON,90006971,CDM,270,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
DRAPE TABLE COVER,90006972,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
ABS FIXATION DEVICE W/15 TACKS,90006979,CDM,270,RC,,,outpatient,,,1500,1125,,1200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,603.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,603.6,1200,
DE-FIB PADS ZOLL REPLACEMENT,90006983,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
Y-TUBE TUR/BLADDER IRRIGATION SET,90006987,CDM,270,RC,,,outpatient,,,27,20.25,,21.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.86,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.86,21.6,
FALL RISK NON SKID SOCK XL,90006999,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
CATHETER BARTHOLIN GLAND WORD,90007002,CDM,270,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
PESSARY DONUT 2 1/2 (PESSARY ONLY),90007009,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY DONUT 2 3/4 (PESSARY ONLY),90007010,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
SUTURE 6-0 PROLENE,90007015,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
THERMISTOR AIR REUSABLE,90007016,CDM,270,RC,,,outpatient,,,400,300,,320,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,300,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.96,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,160.96,320,
TROCAR 5 MM X 150 MM BLADELESS (GYN),90007019,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
LITHIUM/HEPARIN SEPERATOR,90007020,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
HYDROFERA BLUE,90007023,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
"MASK, FULL FACE SMALL",90007024,CDM,270,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
"MASK, FULL FACE MEDIUM",90007025,CDM,270,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
"MASK, FULL FACE LARGE",90007026,CDM,270,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
"TRAY, CONTINOUS EPIDURAL ANESTHESIA",90007027,CDM,270,RC,,,outpatient,,,75,56.25,,60,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,30.18,60,
EXTENSION SET MEDEX 21  ADAPTER,90007031,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
DEVICE MYOSURE TISSUE REMOVAL (GYN),90007039,CDM,270,RC,,,outpatient,,,1600,1200,,1280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,880,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1200,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,643.84,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,643.84,1280,
DEVICE MYOSURE LITE TISSUE REMOVAL (GYN),90007040,CDM,270,RC,,,outpatient,,,1100,825,,880,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,605,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.64,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,442.64,880,
DEVICE NOVASURE DOMESTIC STERILE (GYN),90007041,CDM,270,RC,,,outpatient,,,2083.33,1562.5,,1666.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,838.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1041.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1041.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1041.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1041.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1145.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1666.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,838.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,838.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1666.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1562.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1666.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1666.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,838.33,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1666.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,838.33,1666.66,
CATHETER F6INF IM 100CM 534660T,90007045,CDM,270,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
CATHETER F6INF TL JR 4 100CM 534621T,90007046,CDM,270,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
CATHETER F6INF TL 3DRC 100CM 534676T,90007047,CDM,270,RC,,,outpatient,,,16,12,,12.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.44,12.8,
HANDLE COVER STERIS LIGHT,90007052,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
MANIFOLD 4-PORT NEPTUNE 2,90007077,CDM,270,RC,,,outpatient,,,50,37.5,,40,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.12,40,
DETERGENT NEPTUNE DOCKING,90007078,CDM,270,RC,,,outpatient,,,300,225,,240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,120.72,240,
CURETTE 7 MM CURVED RIGID,90007088,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
CURETTE 10 MM CURVED RIGID,90007089,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
CURETTE 12 MM CURVED RIGID,90007090,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
DRESSING TRANSPARENT FILM 4 X 4,90007104,CDM,270,RC,,,outpatient,,,3,2.25,,2.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.21,2.4,
"PESSARY RING W/SUPP,KNOB,FOLD 2 1/4(KIT)",90007106,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
"PESSARY RING W/SUPP,KNOB,FOLD 2 1/2(KIT)",90007107,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
SET NEEDLE QUICK CORE BIOPSY,90007110,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
CARTRIDGE NOVASURE CO2,90007111,CDM,270,RC,,,outpatient,,,33,24.75,,26.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,13.28,26.4,
DRESSING CALCIUM ALGINATE 4 X 4 SILVER,90007112,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
DEFIB/PACE DUAL,5800108,CDM,275,RC,C1721,HCPCS,outpatient,,,30000,22500,,24000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12072,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16500,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12072,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12072,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12072,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,24000,
INOGEN EL ICD DF4-VR,5890048,CDM,278,RC,C1722,HCPCS,both,,,31000,23250,,24800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12474.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17050,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12474.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12474.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23250,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12474.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10000,24800,
DYNAGEN MINI ICD DR SYSTEM MODEL D022,5890001,CDM,278,RC,C1721,HCPCS,both,,,32500,24375,,26000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13078,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17875,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13078,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13078,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22750,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24375,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13078,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10000,26000,
INSERTION BIV ELECTRODE/NEW GEN PLACED,5800086,CDM,480,RC,33225,HCPCS,outpatient,,,33088,24816,,26470.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19623.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,19623.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,19623.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,16544,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18198.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,26470.4,
INSERTION BIV-ELECTRODE/PREV PLAC GEN,5800087,CDM,480,RC,33224,HCPCS,outpatient,,,33088,24816,,26470.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19623.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,19623.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,19623.07,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,18198.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,8908.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,24816,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13314.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15265.35,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,9540.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,26470.4,
NEONATE PED NASAL CANNULA (RESP),90007157,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
PESSARY INCONTINENCE DISH 2 3/8 (KIT),90007179,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
PESSARY INCONTINENCE DISH 2 1/2 (KIT),90007180,CDM,270,RC,,,outpatient,,,180,135,,144,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,72.43,144,
CURETTE LIGHTED EAR W/MAGNIFICATION,90007219,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
IRRIGATION TIP EAR OTOCLEAR,90007220,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
SYSTEM OTOCLEAR EAR WASH,90007221,CDM,270,RC,,,outpatient,,,240,180,,192,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,96.58,192,
BLADE MAC DISP SZ 2,90007252,CDM,270,RC,,,outpatient,,,10.9,8.18,,8.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.39,8.72,
BLADE MAC DISP SZ 4,90007253,CDM,270,RC,,,outpatient,,,10.9,8.18,,8.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.39,8.72,
BLADE MILLER DISP SZ 2,90007254,CDM,270,RC,,,outpatient,,,10.9,8.18,,8.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.39,8.72,
BLADE MILLER DISP SZ 4,90007255,CDM,270,RC,,,outpatient,,,10.9,8.18,,8.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.39,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.39,8.72,
CYSTOGRAFIN 30% 10X300ML,90007315,CDM,270,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
EXTENSION SET 0.2 MICRON FILTER/MALE LL,90007335,CDM,270,RC,,,outpatient,,,8.45,6.34,,6.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.65,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.4,6.76,
TRACH TIES,90007394,CDM,270,RC,,,outpatient,,,2.4,1.8,,1.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.97,1.92,
HIBICLENS CLEANSING SOAP,90007408,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BLADE DISP FIBER-OPTIC MAC 1,90007425,CDM,270,RC,,,outpatient,,,8.8,6.6,,7.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.54,7.04,
BLADE DISP FIBER-OPTIC MILLER 0,90007426,CDM,270,RC,,,outpatient,,,8.8,6.6,,7.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.54,7.04,
BLADE DISP FIBER-OPTIC MILLER 1,90007427,CDM,270,RC,,,outpatient,,,8.8,6.6,,7.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.54,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.54,7.04,
HANDLE SLIM FIBER-OPTIC LARYNGOSCOPES,90007428,CDM,270,RC,,,outpatient,,,12.8,9.6,,10.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.04,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.15,10.24,
BEDSIDE SCOPE CLEANING KIT W/BAG,90007433,CDM,270,RC,,,outpatient,,,9,6.75,,7.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.95,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.62,7.2,
MANIPULATOR ZINNATI ADJUSTABLE (ZAMI 4.5,90007434,CDM,270,RC,,,outpatient,,,42,31.5,,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.9,33.6,
STAPLES LINEAR PROXIMATE TR 30,90007437,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
VALVE SETS DISP. ENDOSCOPE,90007438,CDM,270,RC,,,outpatient,,,19.28,14.46,,15.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.76,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.76,15.42,
TROCAR 12 X 150MM CTB71,90007442,CDM,270,RC,,,outpatient,,,136,102,,108.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,54.73,108.8,
URINE TRANSFER DEVICE,90007445,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
FALL RISK NON SKID SOCK XXL,90007457,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BLADES CLIPPER PINK,90007463,CDM,270,RC,,,outpatient,,,6.01,4.51,,4.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.31,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.42,4.81,
BAND RESISTANCE BANDS,90007464,CDM,270,RC,,,outpatient,,,9.52,7.14,,7.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.83,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.83,7.62,
NEEDLE INTROCAN SAFETY 1.1 X 64MM,90007470,CDM,270,RC,,,outpatient,,,8.65,6.49,,6.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.76,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.48,6.92,
STAPLER 33 MM CURVED INTRALUMINAL,90007478,CDM,270,RC,,,outpatient,,,510,382.5,,408,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,205.22,408,
ELECTRODE STRESS TEST MACHINE (NEW),90007483,CDM,270,RC,,,outpatient,,,0.34,0.26,,0.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.19,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.14,0.27,
TOURNIQUET COMBAT (CAT) BLACK,90007484,CDM,270,RC,,,outpatient,,,48.26,36.2,,38.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.54,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.42,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,19.42,38.61,
BRUSH BRONCHOSCOPE CYTOLOGY,90007490,CDM,270,RC,,,outpatient,,,57.6,43.2,,46.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,28.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.68,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,23.18,46.08,
ADAPTER SWIVEL Y SONTEK BODAI PEEP,90007508,CDM,270,RC,,,outpatient,,,13.32,9.99,,10.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.36,10.66,
H. PYLORI OSOM KIT,90007525,CDM,270,RC,,,outpatient,,,16.3,12.23,,13.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.97,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.56,13.04,
EXTENSION SET LIPIDS 1.2 MICRON FILTER,90007530,CDM,270,RC,,,outpatient,,,7.28,5.46,,5.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.93,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.93,5.82,
WIPE CLEANSING PATIENT 2%CHG,90007541,CDM,270,RC,,,outpatient,,,11.15,8.36,,8.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.49,8.92,
CANNULA VACURETTE CURVED 8MM,90007543,CDM,270,RC,,,outpatient,,,9.71,7.28,,7.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.91,7.77,
COLLECTION SET TUBING DISP. STERILE,90007544,CDM,270,RC,,,outpatient,,,14.25,10.69,,11.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.73,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.73,11.4,
TRAP TISSUE SAFETOUCH,90007545,CDM,270,RC,,,outpatient,,,19.26,14.45,,15.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.75,15.41,
PUNCH BIOPSY DISP 2MM,90007587,CDM,270,RC,,,outpatient,,,5.04,3.78,,4.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.77,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.03,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.03,4.03,
SIDESTREAM CO2 KIT ADULT,90007615,CDM,270,RC,,,outpatient,,,346.5,259.88,,277.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,173.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,139.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,139.43,277.2,
FILTER BACTERIAL/VIRAL,90007654,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
HUMIDIFIER LARGE HIGH FLOW 350ML DISPOSA,90007658,CDM,270,RC,,,outpatient,,,5.44,4.08,,4.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.99,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.19,4.35,
NASAL CANNULA  ADULT 3-CHANNEL 7FT,90007659,CDM,270,RC,,,outpatient,,,5.3,3.98,,4.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.92,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.13,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.13,4.24,
BREATHRITE CHAMBER W/O MASK,90007697,CDM,270,RC,,,outpatient,,,9.5,7.13,,7.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.23,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.82,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.82,7.6,
FILTER ASPIRATOR (GYN),90007698,CDM,270,RC,,,outpatient,,,13.28,9.96,,10.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.34,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.34,10.62,
SUCTION CANISTER COLLECTION KIT (GYN),90007699,CDM,270,RC,,,outpatient,,,28.22,21.17,,22.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.52,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.36,22.58,
CIRCUIT VAPOTHERM HIGH FLOW DISP PT,90007720,CDM,270,RC,,,outpatient,,,192,144,,153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.26,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,77.26,153.6,
CANNULA VAPOTHERM LONG ADULT,90007722,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
CANNULA VAPOTHERM ADULT,90007723,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
PLEURX KIT PLEURAL CATHETER,90007724,CDM,270,RC,,,outpatient,,,2092.96,1569.72,,1674.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,842.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1046.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1046.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1046.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1046.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1151.13,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,842.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,842.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1674.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1569.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1674.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1674.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,842.21,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1674.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,842.21,1674.37,
LARYNGO-TRACHEAL MUCOSAL ATOMIZATION DEV,90007727,CDM,270,RC,,,outpatient,,,19.81,14.86,,15.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.97,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.97,15.85,
POUCH OSTOMY DRN TRANSP 57MM 2 1/4,90007732,CDM,270,RC,,,outpatient,,,6.04,4.53,,4.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.32,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.43,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.43,4.83,
SKIN BARRIER RING SLIM FIT ADPT,90007733,CDM,270,RC,,,outpatient,,,11.34,8.51,,9.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.24,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.56,9.07,
WAFER SKIN BARRIER CONVE 1 1/2,90007734,CDM,270,RC,,,outpatient,,,22.12,16.59,,17.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.17,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.9,17.7,
STERILE WATER (VAPOTHERM) RESP,90007735,CDM,270,RC,,,outpatient,,,25,18.75,,20,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,10.06,20,
ABDOMINAL BINDER SMALL,90007744,CDM,270,RC,,,outpatient,,,9.72,7.29,,7.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.91,7.78,
AQUILEX TUBING,90007751,CDM,270,RC,,,outpatient,,,46.2,34.65,,36.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,23.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.59,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.59,36.96,
TROCAR ACCESS SYSTEM (CFR03),90007767,CDM,100,RC,,,inpatient,,,34,25.5,,23.8,70,,,percent of total billed charges,70% of billed charges for inpatient setting,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,30.03,88.32,,,percent of total billed charges,88.32% of billed charges for inpatient setting,30.03,88.32,,,percent of total billed charges,88.32% of billed charges for inpatient setting,30.03,88.32,,,percent of total billed charges,88.32% of billed charges for inpatient setting,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",27.2,80,,,percent of total billed charges,80% of billed charges for inpatient setting,25.5,75,,,percent of total billed charges,75% of billed charges for inpatient setting,25.5,75,,,percent of total billed charges,75% of billed charges for inpatient setting,25.5,75,,,percent of total billed charges,75% of billed charges for inpatient setting,25.5,75,,,percent of total billed charges,75% of billed charges for inpatient setting,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,27.2,80,,,percent of total billed charges,80% of billed charges for inpatient setting,27.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,23.8,2737.25,
MESH PARIETENE MACROPOROUS,90007792,CDM,270,RC,,,outpatient,,,208,156,,166.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,83.7,166.4,
SNARE 10MM SD-210U-10,90007796,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
BALEEN POLYP TRAP,90007798,CDM,270,RC,,,outpatient,,,7.9,5.93,,6.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.18,6.32,
SNARE 15 MM  SD-210U-15,90007801,CDM,270,RC,,,outpatient,,,17.41,13.06,,13.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.58,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.01,13.93,
FILTER PG IQ 4 X 25,90007812,CDM,270,RC,,,outpatient,,,4.04,3.03,,3.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.63,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,1.63,3.23,
NOSECLIPS KUSHION KLIP,90007813,CDM,270,RC,,,outpatient,,,1.5,1.13,,1.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.6,1.2,
MASK FULL FACE ADULT MEDIUM,90007821,CDM,270,RC,,,outpatient,,,51.65,38.74,,41.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.78,41.32,
"MASK, FULL FACE FIT PACK",90007822,CDM,270,RC,,,outpatient,,,51.65,38.74,,41.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.78,41.32,
MASK FULL FACE ADULT XLARGE,90007823,CDM,270,RC,,,outpatient,,,51.65,38.74,,41.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.41,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.78,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,20.78,41.32,
ELBOW ICE STANDARD 313-9599,90007824,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
ELBOW ICE ANTI-ASPHYXIA,90007825,CDM,270,RC,,,outpatient,,,10,7.5,,8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.02,8,
SET THAL-QUICK CHEST TUBE,90007830,CDM,270,RC,,,outpatient,,,282.48,211.86,,225.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,141.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.36,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,113.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.67,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,113.67,225.98,
TRAY THAL-QUICK CHEST TUBE,90007831,CDM,270,RC,,,outpatient,,,361.62,271.22,,289.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,180.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.89,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.52,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,145.52,289.3,
CONNECTOR OXYGEN OHMEDA,90007835,CDM,100,RC,,,inpatient,,,,,,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% Cigna Per diem for inpatient stay,1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",1500,100,,,per diem,"100% Coventry per diem rate. Can also pay at 1400, 1800 depending on procedure. Maternity visits are paid at a case rate of 3200",,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,100,,,per diem,"100% Multiplan per diem rate. Can also pay at 1752, 1853 depending on procedure. Maternity visits are paid at a case rate of 2180",,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1500,100,,,per diem,100% PPO Plus per diem rate. Can also pay at 1925 for surgery,,,,,other,Not reimbursable due to charge amount,,,,,other,Not reimbursable due to charge amount,2737.25,100,,,per diem,100% LA Medicaid per diem rate for inpatient stay,,,,,other,Pays at 160% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 140% CMS MS-DRG rates. See MS-DRG rows.,,,,,other,Pays at 100% CMS MS-DRG rates. See MS-DRG rows.,1308,2737.25,
CANNULA ADULT SMALL HIGH FLOW,90007837,CDM,270,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
CANNULA ADULT MEDIUM HI-FLOW,90007838,CDM,270,RC,,,outpatient,,,22,16.5,,17.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.85,17.6,
CANNULA ADULT LARGE HI-FLOW,90007839,CDM,270,RC,,,outpatient,,,44,33,,35.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.71,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,17.71,35.2,
CIRCUIT SINGLE LIMB DRAGER,90007845,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SPLINT WRIST WITH THUMB XS LEFT,90007864,CDM,270,RC,,,outpatient,,,28.78,21.59,,23.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.58,23.02,
SPLINT WRIST WITH THUMB SMALL LEFT,90007865,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
SPLINT WRIST WITH THUMB MEDIUM LEFT,90007866,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
SPLINT WRIST WITH THUMB LARGE LEFT,90007867,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
SPLINT WRIST WITH THUMB XL LEFT,90007868,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
SPLINT WRIST WITH THUMB XS RIGHT,90007869,CDM,270,RC,,,outpatient,,,28.78,21.59,,23.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.83,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.58,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,11.58,23.02,
SPLINT WRIST WITH THUMB SMALL RIGHT,90007870,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
SPLINT WRIST WITH THUMB MEDIUM RIGHT,90007871,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
SPLINT WRIST WITH THUMB LARGE RIGHT,90007872,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
SPLINT WRIST WITH THUMB XL RIGHT,90007873,CDM,270,RC,,,outpatient,,,16.14,12.11,,12.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.88,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.49,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.49,12.91,
HANDLE INTUBRITE LARYNGOSCOPE MEDIUM,90007875,CDM,270,RC,,,outpatient,,,20.25,15.19,,16.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.14,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.15,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.15,16.2,
BLADE INTUBRITE MILLER SZ 3 CHILD MEDIUM,90007876,CDM,270,RC,,,outpatient,,,17.45,13.09,,13.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.02,13.96,
BLADE INTUBRITE MACINTOSH SZ 4 LARYNGOSC,90007877,CDM,270,RC,,,outpatient,,,19.65,14.74,,15.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.81,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.91,15.72,
ACAPELLA PORTEX BLUE PEP THERAPY SYS,90007878,CDM,270,RC,,,outpatient,,,72.2,54.15,,57.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.71,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,29.05,57.76,
TELEMETRY POUCH,90007890,CDM,270,RC,,,outpatient,,,2.36,1.77,,1.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.95,1.89,
BLADE INTUBRITE MACINTOSH SZ 3.5,90007891,CDM,270,RC,,,outpatient,,,17.45,13.09,,13.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.02,13.96,
HANDLE INTUBRITE PEDIATRIC LARYNGSCOPE,90007892,CDM,270,RC,,,outpatient,,,16.56,12.42,,13.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.66,13.25,
PACEMAKER FORTIFYASSURA DR_ICD_UMRI_PR,5890029,CDM,275,RC,C1722,HCPCS,outpatient,,,33500,25125,,26800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13480.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18425,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13480.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13480.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23450,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13480.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,26800,
BLADE LARYNGOSCOPE MACINTOSH SZ 1 INFANT,90007909,CDM,270,RC,,,outpatient,,,17.45,13.09,,13.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.02,13.96,
BLADE LARYNGOSCOPE MACINTOSH SZ 2 CHILD,90007910,CDM,270,RC,,,outpatient,,,18.48,13.86,,14.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.16,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.44,14.78,
BLADE LARYNGOSCOPE MILLER SZ 1 INFANT,90007913,CDM,270,RC,,,outpatient,,,17.44,13.08,,13.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.59,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.02,13.95,
BLADE DUAL LED MILLER SZ 1 INFANT,90007914,CDM,270,RC,,,outpatient,,,17.64,13.23,,14.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.1,14.11,
BLADE MILLER SZ 2 CHILD MEDIUM,90007915,CDM,270,RC,,,outpatient,,,17.45,13.09,,13.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.02,13.96,
BLADE MILLER SZ 4 LARGE ADULT,90007917,CDM,270,RC,,,outpatient,,,17.45,13.09,,13.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.02,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,7.02,13.96,
PESSARY GELLHORN 2 (PESSARY ONLY),90007928,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY GELLHORN 1 3/4 (PESSARY ONLY),90007929,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
PESSARY GELLHORN 2 1/4 (PESSARY ONLY),90007930,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
BRONCHO ASCOPE 4 LARGE (AMBU),90007946,CDM,270,RC,,,outpatient,,,622,466.5,,497.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,311,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,497.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,250.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,466.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,497.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,497.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,250.29,497.6,
KIT BRONCHOSAMPLER DISP,90007957,CDM,270,RC,,,outpatient,,,614,460.5,,491.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,307,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.7,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,247.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,491.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,247.07,491.2,
BRONCHO REGULAR ASCOPE,90007958,CDM,270,RC,,,outpatient,,,807,605.25,,645.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,403.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,403.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,403.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,403.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.85,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,324.74,645.6,
VIVASIGHT SL 8.0 ETT/39 FR,90007981,CDM,270,RC,,,outpatient,,,520,390,,416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,286,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.25,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,209.25,416,
PESSARY DONUT 3 (PESSARY ONLY),90007983,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
STAPLER LINEAR PROX RLOAD 30MM,90007996,CDM,270,RC,,,outpatient,,,942,706.5,,753.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,471,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,518.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.06,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,753.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,379.06,753.6,
SECURLINK BLOOD ID RECIPIENT SYS. (LAB),90008002,CDM,270,RC,,,outpatient,,,5,3.75,,4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.01,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2.01,4,
BLADE LARYNGOSCOPE SZ 0 MILLER INTUBRITE,90008016,CDM,270,RC,,,outpatient,,,12.4,9.3,,9.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6.82,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.99,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.99,9.92,
BLADE LARYNGOSCOPE MACINTOSH #4 DISP,90008022,CDM,270,RC,,,outpatient,,,9.72,7.29,,7.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.35,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.91,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.91,7.78,
STYLET GLIDERITE SINGLE USE LARGE,90008048,CDM,270,RC,,,outpatient,,,21,15.75,,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.45,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.45,16.8,
LIGASURE CURVED LARGE JAW IMPACT LF4418,90008077,CDM,270,RC,,,outpatient,,,1107.4,830.55,,885.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,445.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,553.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,553.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,553.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,553.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,609.07,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,885.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,445.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,830.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,885.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,885.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,445.62,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,445.62,885.92,
SET SUPER ARROW-FLEX PSI (SHEATH INTRO),90008098,CDM,270,RC,,,outpatient,,,80,60,,64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.19,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,32.19,64,
TUBING INSUFFLATION HEATED,90008154,CDM,270,RC,,,outpatient,,,316,237,,252.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.8,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.16,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,127.16,252.8,
CATHETER SET HSG/HG KRATON 5FR,90008155,CDM,270,RC,,,outpatient,,,66.36,49.77,,53.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.7,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.7,53.09,
COVID TESTING INHOUSE (1 TEST),90008174,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
DIALATOR BALLOON ESPOHAGEAL (000344),90008178,CDM,270,RC,,,outpatient,,,148,111,,118.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.56,118.4,
DILATOR BALLOON ESOPHAGEAL (000345),90008179,CDM,270,RC,,,outpatient,,,148,111,,118.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,59.56,118.4,
TUBE HOLDER NEONATAL (NEOBAR) GREEN,90008218,CDM,270,RC,,,outpatient,,,38,28.5,,30.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.29,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,15.29,30.4,
ADAPTERS/ACCESSORIES PACEMAKER,90008224,CDM,278,RC,,,both,,,700,525,,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,385,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,525,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,281.68,700,
ISOVUE 370 10X75ML BTL,90008234,CDM,270,RC,,,outpatient,,,14.71,11.03,,11.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.09,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.92,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,5.92,11.77,
TUBE HOLDER NEONATAL ET WHITE,90008236,CDM,270,RC,,,outpatient,,,41.13,30.85,,32.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.62,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.55,32.9,
BLADE LARYNGOSCOPE INTUBRITE MILLER 0,90008283,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
HOSE CONNECTOR TUBING OLYMPUS GYRUS,90008291,CDM,270,RC,,,outpatient,,,8,6,,6.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,3.22,6.4,
SUCTION CANISTER OLYMPUS SAFETOUCH W/SNA,90008292,CDM,270,RC,,,outpatient,,,24,18,,19.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.2,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,9.66,19.2,
SLIDING TABLE DRAPE FOR STERIS,90008302,CDM,270,RC,,,outpatient,,,30.26,22.7,,24.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.64,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.18,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.18,24.21,
KIT PERCUTANEOUS TRACHEOSTOMY INTRODUCER,90008322,CDM,270,RC,,,outpatient,,,1032,774,,825.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,516,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,516,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,516,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,516,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,567.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,774,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,415.28,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,415.28,825.6,
SWAN-GANZ CATHETER 110F5,90008323,CDM,270,RC,,,outpatient,,,285,213.75,,228,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.68,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,114.68,228,
CARTRIDGE BLOOD GAS/COOX,90008337,CDM,270,RC,,,outpatient,,,30,22.5,,24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.07,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.07,24,
EVALUATOR LEVEL 1 GEM SYSTEM,90008338,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
EVALUATOR LEVEL 2 GEM SYSTEM,90008339,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
EVALUATOR LEVEL 3 GEM SYSTEM,90008340,CDM,270,RC,,,outpatient,,,40,30,,32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,16.1,32,
MEDTRONIC ICD-VR DVFB1D1 VISIA AF MRI US,5890030,CDM,275,RC,C1785,HCPCS,outpatient,,,33640,25230,,26912,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13536.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16820,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16820,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16820,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16820,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18502,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25230,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25230,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25230,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25230,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13536.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13536.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25230,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26912,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13536.74,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,26912,
KRYSTEXXA 8 MG/NSS 250mL,3205901,CDM,636,RC,J2507,HCPCS,both,,,34500,25875,,27600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13882.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5433.13,50,,,fee schedule,50% of CMS Medicare OPPS fee schedule for outpatient setting,18975,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5433.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5433.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,5433.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,13882.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,13882.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5433.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5433.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,25875,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13882.8,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5291.28,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,5433.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,4960.57,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4960.57,27600,
DEVICE INTRANASAL MUSCOSAL ATOMIZATION,90008350,CDM,270,RC,,,outpatient,,,35,26.25,,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.08,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,14.08,28,
MYOSURE SEAL SETS,90008353,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SWAN-GANZ CATHETER 111F7,90008354,CDM,270,RC,,,outpatient,,,291,218.25,,232.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.05,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,117.1,232.8,
NASAL PAC RAPID RHINO EPISTAXIS (RR750),90008372,CDM,270,RC,,,outpatient,,,66,49.5,,52.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.56,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,26.56,52.8,
NASAL PAC RAPID RHINO EPISTAXIS (RR550),90008373,CDM,270,RC,,,outpatient,,,89.7,67.28,,71.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.34,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.1,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.1,71.76,
ATTACHMENT SMOKE EVACUATOR (VALLEY LAB),90008381,CDM,270,RC,,,outpatient,,,85,63.75,,68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,34.2,68,
PENCIL VL SMOKE EVACUATION ROCKER SWITCH,90008387,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
INTRODUCER KIT 6 FR GALT TEARAWAY,90008392,CDM,270,RC,,,outpatient,,,121,90.75,,96.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.69,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,48.69,96.8,
INTRODUCER ONLY 11FR TEARAWAY,90008393,CDM,270,RC,,,outpatient,,,60,45,,48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.14,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.14,48,
SUTURE MONOCRYL 5-0 P3 (Y493G),90008394,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SUTURE MONOCRYL 6-0 P3 (Y492G),90008395,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
SUTURE PROLENE 4-0 PS-2 (8682G),90008396,CDM,270,RC,,,outpatient,,,20,15,,16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.05,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,8.05,16,
KIT INFLUENZA  A & B (ABBOTT - LAB),90008452,CDM,270,RC,,,outpatient,,,158.07,118.55,,126.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,79.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.94,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,63.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.61,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,63.61,126.46,
KIT STREP A-2 (LAB USE),90008453,CDM,270,RC,,,outpatient,,,98,73.5,,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.9,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.44,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,39.44,78.4,
"CARTRIDGE GEM5000 PAK PH,PCO2,HCL SENSOR",90008477,CDM,270,RC,,,outpatient,,,62,46.5,,49.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,24.95,49.6,
COVID TEST BINAXNOW RAPID TEST,90008480,CDM,270,RC,,,outpatient,,,32,24,,25.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,12.88,25.6,
NEBULIZER HUDSON RCI ISO-NEB FILTERED,90008488,CDM,270,RC,,,outpatient,,,10.61,7.96,,8.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.84,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.27,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,4.27,8.49,
PESSARY RING W/SUPPORT 1 3/4 (KIT),90008513,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PESSARY RING W/SUPPORT 2 (KIT),90008514,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PESSARY RING W/SUPPORT 2 1/4 (KIT),90008515,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PESSARY RING W/SUPPORT 2 1/2 (KIT),90008516,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
PESSARY RING W/SUPPORT 2 3/4 (KIT),90008517,CDM,270,RC,,,outpatient,,,150,112.5,,120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.36,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,60.36,120,
VENTURI MASK % 02 LOCK ADULT 7FT,90008520,CDM,270,RC,,,outpatient,,,15,11.25,,12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.25,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,6.04,12,
APPLIER CLIP LIGAMAX EL5ML,90009855,CDM,270,RC,,,outpatient,,,253,189.75,,202.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,126.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.15,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,101.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.81,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,101.81,202.4,
INSERTION OF SINGLE OR DUAL CHAM ICD GEN,5800088,CDM,480,RC,33240,HCPCS,outpatient,,,42522,31891.5,,34017.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,54324.66,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,54324.66,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,54324.66,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23387.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19680.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19680.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19680.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33724.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,54324.66,
GUIDEWIRE HYDROPHILIC 260 CM,90009964,CDM,270,RC,,,outpatient,,,90,67.5,,72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.5,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,36.22,72,
ACIST SYRINGE A2000,90009975,CDM,270,RC,,,outpatient,,,45,33.75,,36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.75,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.11,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,18.11,36,
PESSARY GELLHORN 1 1/2 (PESSARY ONLY),90011107,CDM,270,RC,,,outpatient,,,146,109.5,,116.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.3,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.75,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,58.75,116.8,
NASAL MASK DISPOSABLE  5/PK RESP.,99999223,CDM,270,RC,,,outpatient,,,1,0.75,,0.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.55,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.4,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,0.4,0.8,
REMOVL AND REPLACE AICD GEN. DUEL CHAM,5800158,CDM,480,RC,33263,HCPCS,outpatient,,,42522,31891.5,,34017.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,76197.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,76197.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,76197.9,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,23387.1,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19680.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19680.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,19680.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,31891.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34017.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17110.85,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,33724.23,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,21077.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,76197.9,
INSERTION/REPOSITION OF ICD SYSTEM,5800089,CDM,480,RC,33249,HCPCS,outpatient,,,51572,38679,,41257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20752.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,44082.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,44082.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,44082.17,135,,,fee schedule,135% BCBS ASC fee schedule for outpatient setting,29629.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,28364.6,55,,,percent of total billed charges,55% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2500,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38679,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38679,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38679,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38679,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27665.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27665.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,27665.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,20752.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,20752.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,29629.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,41257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29629.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,38679,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20752.57,40.24,,,percent of total billed charges,40.24% of total billed charges for outpatient setting which is 100% of the LA Medicaid rate,47407.06,160,,,fee schedule,160% CMS Medicare OPPS fee schedule for outpatient setting,29629.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule for outpatient setting,,140,,,fee schedule,140% CMS Medicare OPPS fee schedule for outpatient setting,10000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting not to exceed 10000,2500,47407.06,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,217860.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,192671.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,192671.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,192671.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,217860.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,326791.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,217860.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,305005.39,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,192671.05,326791.49,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,99015.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87055.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,87055.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,87055.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,99015.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,148522.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,99015.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,138621.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87055.55,148522.56,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,171630.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,151587.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,151587.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,151587.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,171630.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,257446.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,171630.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,240282.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,151587.32,257446.07,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,118663.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,104517.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,104517.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,104517.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,118663.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,177995.82,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,118663.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,166129.43,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,104517.01,177995.82,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,83860.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,73588.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,73588.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,73588.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,83860.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,125791.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,83860.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,117405.36,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,73588.5,125791.46,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39752.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34390.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34390.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34390.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39752.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,59628.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,39752.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,55653.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34390.36,59628.71,
LUNG TRANSPLANT,7,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,99193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87214.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,87214.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,87214.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,99193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,148790.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,99193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,138870.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87214.09,148790.18,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43151.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37410.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37410.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37410.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43151.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,64726.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,43151.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,60411.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37410.69,64726.74,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39566.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34224.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34224.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34224.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39566.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,59349.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,39566.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,55392.48,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34224.7,59349.09,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42307.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36661.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36661.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36661.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42307.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,63461.84,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,42307.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,59231.05,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36661.29,63461.84,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33095.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28474.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28474.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28474.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33095.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49643.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,33095.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,46334.29,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28474.85,49643.88,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22541.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19095.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19095.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19095.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22541.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33812.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22541.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31558.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19095.32,33812.16,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,92748.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,81487,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,81487,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,81487,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,92748.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,139123.37,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,92748.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,129848.47,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,81487,139123.37,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50474.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43918.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43918.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43918.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50474.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,75711.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,50474.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,70663.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43918.47,75711.27,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50474.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43918.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43918.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43918.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50474.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,75711.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,50474.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,70663.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43918.47,75711.27,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,295820.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,261951.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,261951.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,261951.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,295820.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,443730.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,295820.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,414148.43,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,261951.59,443730.47,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,65007.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56833.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,56833.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,56833.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,65007.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,97511.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,65007.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,91010.35,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56833.78,97511.09,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,68678.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,60096.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,60096.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,60096.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,68678.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,103018.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,68678.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,96150.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,60096.57,103018.35,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50189.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43665.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43665.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43665.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50189.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,75284.03,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,50189.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,70265.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43665.36,75284.03,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32438.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27890.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27890.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27890.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32438.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48657.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,32438.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45413.58,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27890.4,48657.41,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46408.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40305.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40305.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40305.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46408.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,69612.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,46408.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,64971.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40305.16,69612.36,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31366.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26938.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26938.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26938.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31366.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,47050.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,31366.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43913.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26938.36,47050.46,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36385,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31397.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31397.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31397.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36385,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,54577.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,36385,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,50939,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31397.76,54577.5,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24680.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20996.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20996.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20996.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24680.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37021.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24680.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34553.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20996.54,37021.22,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20518.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17297.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17297.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17297.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20518.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30778.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20518.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28726.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17297.92,30778.29,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49266.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42845.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42845.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42845.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49266.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,73900.31,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,49266.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,68973.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42845.56,73900.31,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28481.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24374.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24374.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24374.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28481.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42722.91,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28481.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39874.72,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24374.5,42722.91,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19607.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16488.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16488.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16488.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19607.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29411.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19607.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27450.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16488.09,29411.39,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33989.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29269.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29269.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29269.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33989.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50984.4,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,33989.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,47585.44,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29269.03,50984.4,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18285.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15313.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15313.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15313.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18285.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27428.82,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18285.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25600.23,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15313.52,27428.82,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14038.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11538.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11538.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11538.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14038.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21057.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14038.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19653.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11538.82,21057.5,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32267.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27738.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27738.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27738.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32267.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48401.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,32267.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45174.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27738.95,48401.78,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19451.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16349.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16349.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16349.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19451.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29177.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19451.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27232.23,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16349.44,29177.39,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15520.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12856.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12856.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12856.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15520.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23281.26,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15520.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21729.18,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12856.3,23281.26,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28061.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24000.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24000.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24000.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28061.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42091.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28061.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39285.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24000.51,42091.65,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13854.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11375.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11375.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11375.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13854.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20781.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13854.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19396.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11375.29,20781.47,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10182.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8112.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8112.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8112.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10182.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15274.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10182.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14255.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8112.52,15274.2,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31860.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27377.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27377.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27377.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31860.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,47790.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,31860.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44604.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27377.05,47790.92,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18901.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15860.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15860.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15860.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18901.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28351.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18901.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26461.6,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15860.27,28351.71,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14973.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12369.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12369.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12369.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14973.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22460.4,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14973.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20963.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12369.98,22460.4,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16611.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13825.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13825.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13825.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16611.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24917.03,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16611.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23255.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13825.4,24917.03,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6994.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6994.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6994.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13387.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12495.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6994.81,13387.65,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12843.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10476.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10476.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10476.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12843.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19264.55,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12843.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17980.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10476.58,19264.55,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9640.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7630.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7630.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7630.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9640.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14460.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9640.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13496.5,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7630.45,14460.54,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20207.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17021.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17021.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17021.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20207.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30311.48,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20207.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28290.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17021.34,30311.48,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11960.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9692.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9692.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9692.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11960.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17940.83,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11960.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16744.77,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9692.35,17940.83,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14878.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12285.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12285.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12285.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14878.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22317.59,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14878.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20829.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12285.37,22317.59,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10552.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8440.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8440.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8440.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10552.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15828.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10552.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14773.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8440.99,15828.65,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8233.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6380.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6380.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6380.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8233.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12350.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8233.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11527.38,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6380.51,12350.76,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23478.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19927.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19927.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19927.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23478.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35217.48,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23478.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32869.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19927.91,35217.48,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16028.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13307.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13307.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13307.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16028.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24043.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16028.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22440.45,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13307.79,24043.34,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12949.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10571.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10571.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10571.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12949.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19424.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12949.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18129.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10571.16,19424.16,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17079.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14241.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14241.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14241.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17079.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25619.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17079.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23911.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14241.34,25619.07,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9185.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7226.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7226.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7226.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9185.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13778.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9185.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12860.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7226.6,13778.87,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6554.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4888.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4888.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4888.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6554.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9831.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6554.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9176.3,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4888.12,9831.75,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12390.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10074.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10074.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10074.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12390.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18585.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12390.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17346.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10074.16,18585.29,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8022.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6192.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6192.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6192.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8022.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12033.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8022.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11231.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6192.81,12033.95,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7444.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5678.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5678.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5678.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7444.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11166.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7444.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10421.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5678.75,11166.27,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15371.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12723.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12723.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12723.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15371.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23056.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15371.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21519.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12723.35,23056.86,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9549.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7549.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7549.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7549.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9549.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14323.73,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9549.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13368.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7549.4,14323.73,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7318.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5567.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5567.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5567.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7318.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10977.84,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7318.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10245.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5567.14,10977.84,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13159.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10757.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10757.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10757.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13159.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19738.58,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13159.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18422.67,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10757.43,19738.58,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9264.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7296.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7296.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7296.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9264.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13896.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9264.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12970.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7296.28,13896.5,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16365.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13607.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13607.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13607.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16365.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24548.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16365.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22911.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13607.12,24548.57,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8434.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6558.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6558.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6558.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8434.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12651.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8434.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11808.51,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6558.98,12651.98,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13142.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10742.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10742.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10742.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13142.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19713.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13142.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18399.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10742.5,19713.38,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9189.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7230.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7230.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7230.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9189.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13784.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9189.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12865.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7230.15,13784.88,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6980.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5267.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5267.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5267.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6980.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10471.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6980.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9773.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5267.08,10471.41,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18725.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15703.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15703.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15703.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18725.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28087.67,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18725.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26215.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15703.85,28087.67,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8330.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6466.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6466.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6466.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8330.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12495.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8330.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11662.91,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6466.54,12495.98,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19281.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16198.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16198.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16198.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19281.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28922.94,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19281.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26994.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16198.71,28922.94,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11906.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9644,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9644,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9644,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11906.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17859.23,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11906.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16668.61,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9644,17859.23,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8412.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6539.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6539.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6539.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8412.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12618.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8412.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11777.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6539.07,12618.38,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19237.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16159.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16159.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16159.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19237.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28856.94,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19237.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26933.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16159.61,28856.94,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11591.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9364.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9364.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9364.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11591.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17387.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11591.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16228.39,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9364.58,17387.57,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8144.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6300.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6300.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6300.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8144.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12216.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8144.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11401.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6300.88,12216.35,
CONCUSSION WITH MCC,88,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13325.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10905.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10905.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10905.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13325.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19988.21,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13325.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18655.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10905.31,19988.21,
CONCUSSION WITH CC,89,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10254.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8175.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8175.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8175.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10254.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15381.02,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10254.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14355.61,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8175.79,15381.02,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8533.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6646.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6646.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6646.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8533.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12799.59,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8533.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11946.28,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6646.43,12799.59,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15368.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12721.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12721.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12721.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15368.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23053.26,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15368.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21516.38,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12721.21,23053.26,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9263.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7295.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7295.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7295.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9263.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13895.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9263.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12968.91,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7295.58,13895.27,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7249.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5505.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5505.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5505.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7249.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10874.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7249.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10149.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5505.99,10874.64,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30038.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25757.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25757.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25757.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30038.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45057.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30038.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42053.28,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25757.39,45057.09,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20129.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16951.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16951.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16951.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20129.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30193.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20129.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28180.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16951.67,30193.86,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18493.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15497.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15497.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15497.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18493.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27739.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18493.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25890.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15497.66,27739.65,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30151.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25858.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25858.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25858.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30151.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45227.51,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30151.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42212.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25858.36,45227.51,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18291.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15318.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15318.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15318.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18291.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27437.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18291.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25608.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15318.5,27437.24,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11616.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9386.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9386.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9386.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11616.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17424.77,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11616.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16263.11,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9386.63,17424.77,
SEIZURES WITH MCC,100,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16915.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14095.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14095.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14095.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16915.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25373.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16915.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23681.5,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14095.57,25373.04,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8331.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6467.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6467.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6467.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8331.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12497.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8331.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11664.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6467.26,12497.18,
HEADACHES WITH MCC,102,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10707.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8578.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8578.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8578.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10707.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16061.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10707.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14990.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8578.93,16061.46,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7793.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5989.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5989.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5989.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7793.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11690.7,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7793.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10911.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5989.47,11690.7,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21114.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17826.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17826.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17826.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21114.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31671.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21114.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29559.77,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17826.9,31671.18,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10909.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8758.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8758.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8758.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10909.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16363.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10909.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15272.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8758.09,16363.89,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13570.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11122.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11122.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11122.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13570.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20355.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13570.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18998.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11122.88,20355.44,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15701.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13016.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13016.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13016.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15701.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23552.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15701.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21982.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13016.99,23552.49,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10642.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8520.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8520.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8520.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10642.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15963.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10642.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14898.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8520.63,15963.06,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11304.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9109.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9109.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9109.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11304.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16956.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11304.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15826.3,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9109.34,16956.75,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7010.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5293.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5293.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5293.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7010.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10515.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7010.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9814.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5293.39,10515.81,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7486.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5716.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5716.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5716.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7486.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11229.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7486.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10481.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5716.45,11229.86,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11630.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9398.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9398.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9398.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11630.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17445.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11630.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16282.18,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9398.71,17445.2,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7434.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5670.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5670.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5670.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7434.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11151.84,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7434.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10408.38,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5670.23,11151.84,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22272.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18856.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18856.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18856.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22272.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33408.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22272.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31181.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18856.43,33408.92,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9409.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7424.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7424.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7424.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9409.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14113.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9409.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13172.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7424.98,14113.71,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13092.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10698.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10698.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10698.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13092.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19638.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13092.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18329.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10698.41,19638.98,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7980.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6155.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6155.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6155.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7980.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11970.32,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7980.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11172.29,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6155.13,11970.32,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10556.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8444.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8444.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8444.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10556.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15834.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10556.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14779,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8444.54,15834.65,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31281.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26862.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26862.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26862.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31281.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46922.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,31281.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43793.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26862.28,46922.04,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17629.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14729.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14729.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14729.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17629.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26443.53,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17629.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24680.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14729.8,26443.53,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13415.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10984.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10984.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10984.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13415.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20122.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13415.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18781.11,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10984.96,20122.62,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27661.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23645.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23645.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23645.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27661.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41491.59,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27661.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38725.48,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23645.02,41491.59,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14899.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12303.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12303.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12303.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14899.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22348.8,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14899.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20858.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12303.86,22348.8,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10823.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8682.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8682.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8682.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10823.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16235.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10823.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15153.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8682.02,16235.49,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17943.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15009.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15009.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15009.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17943.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26915.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17943.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25120.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15009.2,26915.18,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10941.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8786.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8786.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8786.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10941.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16411.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10941.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15317.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8786.54,16411.89,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8172.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6325.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6325.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6325.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8172.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12258.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8172.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11441.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6325.76,12258.36,
DYSEQUILIBRIUM,149,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7012.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5294.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5294.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5294.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7012.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10518.21,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7012.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9817,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5294.81,10518.21,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11570.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9346.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9346.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9346.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11570.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17356.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11570.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16199.29,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9346.1,17356.38,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7220.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5479.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5479.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5479.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7220.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10830.23,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7220.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10108.21,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5479.68,10830.23,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10560.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8448.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8448.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8448.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10560.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15840.66,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10560.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14784.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8448.1,15840.66,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6932.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5224.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5224.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5224.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6932.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10399.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6932.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9706.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5224.42,10399.41,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13360.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10936.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10936.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10936.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13360.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20041.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13360.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18704.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10936.6,20041.01,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8627.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6730.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6730.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6730.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8627.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12941.19,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8627.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12078.44,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6730.33,12941.19,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6298.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4660.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4660.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4660.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6298.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9447.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6298.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8817.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4660.6,9447.71,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14711.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12136.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12136.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12136.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14711.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22066.79,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14711.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20595.67,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12136.77,22066.79,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8562.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6672.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6672.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6672.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8562.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12844.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8562.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11987.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6672.73,12844.01,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6456.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4800.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4800.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4800.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6456.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9684.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6456.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9038.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4800.68,9684.15,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38766,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33513.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33513.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33513.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38766,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,58149,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,38766,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,54272.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33513.7,58149,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21458.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18133.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18133.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18133.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21458.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32188.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21458.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30042.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18133.35,32188.41,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16066.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13341.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13341.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13341.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16066.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24099.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16066.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22493.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13341.2,24099.74,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33519.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28850.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28850.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28850.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33519.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50278.73,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,33519.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,46926.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28850.96,50278.73,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15613.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12938.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12938.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12938.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15613.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23420.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15613.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21859.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12938.78,23420.49,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11900.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9639.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9639.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9639.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11900.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17850.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11900.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16660.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9639.03,17850.81,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25656.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21863.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21863.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21863.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25656.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38484.14,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25656.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35918.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21863.25,38484.14,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12278.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9975.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9975.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9975.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12278.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18418.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12278.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17190.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9975.33,18418.47,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7579.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5798.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5798.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5798.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7579.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11369.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7579.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10611.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5798.91,11369.09,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14626.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12061.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12061.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12061.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14626.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21939.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14626.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20476.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12061.41,21939.56,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8948.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7015.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7015.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7015.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8948.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13422.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8948.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12527.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7015.44,13422.45,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7160.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5427.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5427.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5427.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7160.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10741.43,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7160.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10025.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5427.06,10741.43,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14960.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12358.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12358.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12358.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14960.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22441.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14960.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20945.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12358.61,22441.2,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9863.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7828.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7828.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7828.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9863.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14795.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9863.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13809,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7828.82,14795.36,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7444.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5679.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5679.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5679.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7444.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11167.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7444.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10422.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5679.47,11167.46,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13651.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11194.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11194.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11194.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13651.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20476.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13651.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19111.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11194.7,20476.65,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9469.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7479.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7479.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7479.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9469.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14204.91,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9469.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13257.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7479.01,14204.91,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7100.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5373.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5373.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5373.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7100.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10650.21,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7100.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9940.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5373.03,10650.21,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13471.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11035.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11035.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11035.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13471.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20207.82,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13471.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18860.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11035.44,20207.82,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9025.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7083.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7083.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7083.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9025.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13537.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9025.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12635.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7083.7,13537.65,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7026.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5307.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5307.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5307.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7026.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10539.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7026.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9837.16,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5307.62,10539.81,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10910.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8759.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8759.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8759.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10910.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16366.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10910.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15275.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8759.52,16366.29,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9870.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7835.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7835.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7835.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9870.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14806.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9870.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13819.08,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7835.23,14806.16,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7846.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6036.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6036.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6036.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7846.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11769.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7846.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10985.25,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6036.39,11769.92,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6188.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4563.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4563.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4563.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6188.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9283.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6188.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8664.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4563.2,9283.29,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11667.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9432.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9432.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9432.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11667.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17501.6,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11667.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16334.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9432.13,17501.6,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7632.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5845.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5845.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5845.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7632.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11448.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7632.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10685.07,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5845.84,11448.29,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6059.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4448.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4448.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4448.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6059.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9088.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6059.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8482.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4448.02,9088.89,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16218.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13476.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13476.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13476.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16218.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24327.77,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16218.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22705.91,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13476.29,24327.77,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9034.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7092.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7092.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7092.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9034.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13552.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9034.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12648.59,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7092.22,13552.07,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7280.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5533,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5533,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5533,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7280.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10920.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7280.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10192.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5533,10920.24,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15248.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12613.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12613.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12613.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15248.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22872.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15248.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21347.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12613.84,22872.05,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9670.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7657.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7657.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7657.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9670.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14506.14,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9670.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13539.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7657.47,14506.14,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6703.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5020.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5020.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5020.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6703.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10054.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6703.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9384.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5020.37,10054.97,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8714.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6807.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6807.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6807.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8714.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13072.02,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8714.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12200.55,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6807.82,13072.02,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6613.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4940.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4940.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4940.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6613.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9920.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6613.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9259.19,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4940.74,9920.57,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7637.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5850.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5850.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5850.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7637.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11456.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7637.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10692.91,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5850.82,11456.69,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15537.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12871.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12871.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12871.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15537.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23306.48,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15537.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21752.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12871.23,23306.48,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8362.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6494.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6494.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6494.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8362.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12543.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8362.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11707.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6494.98,12543.98,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56322.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49115.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49115.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49115.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56322.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,84483.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,56322.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,78851.72,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49115.87,84483.99,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22686.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19224.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19224.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19224.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22686.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34029.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22686.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31760.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19224.02,34029.38,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87226.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,76579.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,76579.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,76579.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87226.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,130840.28,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,87226.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,122117.59,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,76579.67,130840.28,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,82779.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,72627.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,72627.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,72627.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,82779.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,124168.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,82779.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,115890.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,72627.22,124168.92,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,78702.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,69004.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,69004.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,69004.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,78702.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,118054.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,78702.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,110184.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,69004.68,118054.41,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51980.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45257.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45257.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45257.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51980.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,77971.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,51980.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,72772.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45257.29,77971.05,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46631.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40503.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40503.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40503.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46631.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,69947.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,46631.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,65284.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40503.53,69947.18,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,62748.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,54826.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,54826.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,54826.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,62748.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,94123.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,62748.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,87848.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,54826.63,94123.2,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43014.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37289.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37289.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37289.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43014.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,64521.53,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,43014.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,60220.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37289.1,64521.53,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38245.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33051.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33051.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33051.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38245.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,57368.93,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,38245.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,53544.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33051.54,57368.93,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41367.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35825.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35825.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35825.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41367.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,62050.52,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,41367.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,57913.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35825.15,62050.52,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26492.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22606.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22606.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22606.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26492.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39739.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26492.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37090.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22606.96,39739.44,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,65981.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,57699.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,57699.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,57699.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,65981.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,98971.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,65981.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,92373.5,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,57699.07,98971.61,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48646.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42294.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42294.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42294.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48646.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,72970.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,48646.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,68105.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42294.55,72970.22,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,63456.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55455.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,55455.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,55455.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,63456.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,95184.08,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,63456.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,88838.47,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55455.15,95184.08,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42640.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36957.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36957.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36957.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42640.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,63961.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,42640.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,59696.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36957.08,63961.07,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48102.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41811.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,41811.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,41811.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48102.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,72154.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,48102.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,67343.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41811.07,72154.16,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33386.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28732.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28732.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28732.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33386.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50079.53,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,33386.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,46740.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28732.93,50079.53,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39511.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34176.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34176.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34176.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39511.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,59267.48,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,39511.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,55316.31,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34176.35,59267.48,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23529.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19973.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19973.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19973.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23529.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35294.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23529.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32941.31,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19973.41,35294.27,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12206.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9911.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9911.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9911.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12206.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18310.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12206.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17089.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9911.33,18310.46,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28697.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24565.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24565.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24565.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28697.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43045.73,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28697.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40176.01,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24565.76,43045.73,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19276.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16193.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16193.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16193.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19276.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28914.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19276.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26986.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16193.73,28914.54,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15691.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13007.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13007.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13007.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15691.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23536.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15691.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21967.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13007.74,23536.89,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37308.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32218.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32218.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32218.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37308.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55962.42,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,37308.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,52231.59,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32218.25,55962.42,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19862,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16714.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16714.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16714.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19862,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29793,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19862,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27806.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16714.19,29793,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13750.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11282.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11282.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11282.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13750.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20625.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13750.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19250.42,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11282.87,20625.45,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27886.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23845.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23845.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23845.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27886.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41830.02,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27886.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39041.35,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23845.52,41830.02,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21464.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18138.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18138.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18138.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21464.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32196.83,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21464.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30050.37,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18138.32,32196.83,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14936,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12336.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12336.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12336.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14936,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22404,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14936,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20910.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12336.55,22404,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23035.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19534.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19534.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19534.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23035.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34552.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23035.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32249.11,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19534.01,34552.62,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14172.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11658.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11658.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11658.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14172.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21259.1,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14172.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19841.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11658.26,21259.1,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8982.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7046,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7046,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7046,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8982.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13474.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8982.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12575.78,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7046,13474.05,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22724.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19258.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19258.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19258.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22724.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34086.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22724.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31814.51,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19258.14,34086.98,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15988.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13271.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13271.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13271.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15988.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23982.14,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15988.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22383.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13271.52,23982.14,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27577.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23571.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23571.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23571.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27577.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41366.79,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27577.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38609,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23571.06,41366.79,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16109.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13379.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13379.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13379.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16109.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24164.55,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16109.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22553.58,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13379.59,24164.55,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14217.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11698.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11698.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11698.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14217.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21326.31,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14217.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19904.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11698.08,21326.31,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23657.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20087.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20087.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20087.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23657.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35486.31,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23657.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33120.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20087.18,35486.31,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27184.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23221.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23221.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23221.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27184.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40776.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27184.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38057.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23221.27,40776.35,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29329.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25127.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25127.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25127.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29329.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43993.82,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,29329.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,41060.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25127.45,43993.82,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51027.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44409.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44409.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44409.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51027.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,76540.53,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,51027.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,71437.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44409.77,76540.53,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40098.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34698.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34698.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34698.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40098.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,60148.37,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,40098.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,56138.47,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34698.23,60148.37,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55896.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48736.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48736.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48736.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55896.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,83844.33,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,55896.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,78254.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48736.91,83844.33,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34325.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29567.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29567.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29567.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34325.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51488.42,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,34325.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48055.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29567.65,51488.42,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41512.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35954.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35954.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35954.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41512.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,62268.93,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,41512.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,58117.67,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35954.55,62268.93,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28705.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24573.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24573.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24573.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28705.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43058.93,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28705.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40188.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24573.59,43058.93,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20571.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17344.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17344.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17344.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20571.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30857.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20571.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28800.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17344.84,30857.49,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32232.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27707.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27707.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27707.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32232.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48348.96,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,32232.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45125.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27707.67,48348.96,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26982.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23042.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23042.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23042.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26982.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40473.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26982.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37775.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23042.08,40473.92,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,57345.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50024.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,50024.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,50024.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,57345.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,86017.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,57345.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,80283.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50024.54,86017.71,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50739.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44154.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44154.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44154.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50739.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,76109.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,50739.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,71035.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44154.53,76109.69,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39316.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34002.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34002.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34002.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39316.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,58974.66,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,39316.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,55043.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34002.87,58974.66,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36740.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31713.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31713.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31713.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36740.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55110.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,36740.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,51436.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31713.45,55110.35,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26660.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22756.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22756.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22756.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26660.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39991.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26660.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37325.37,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22756.26,39991.47,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13747.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13747.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20620.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13747.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19245.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11280.02,20620.65,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8358.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6491.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6491.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6491.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8358.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12537.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8358.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11702.11,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6491.43,12537.98,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6799.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5105.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5105.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5105.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6799.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10198.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6799.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9519.05,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5105.69,10198.98,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16826.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14016.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14016.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14016.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16826.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25239.84,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16826.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23557.18,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14016.66,25239.84,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6972.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5259.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5259.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5259.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6972.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10458.21,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6972.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9761,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5259.26,10458.21,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4963.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3474.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3474.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3474.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4963.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7445.96,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,4963.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6949.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3474.66,7445.96,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18300.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15326.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15326.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15326.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18300.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27450.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18300.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25620.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15326.32,27450.44,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9707.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7690.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7690.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7690.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9707.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14561.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9707.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13590.58,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7690.17,14561.34,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21799.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18436.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18436.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18436.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21799.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32699.66,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21799.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30519.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18436.23,32699.66,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12876.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10506.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10506.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10506.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12876.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19314.93,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12876.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18027.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10506.44,19314.93,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9735.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7715.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7715.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7715.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9735.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14603.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9735.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13629.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7715.05,14603.36,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11326.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9128.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9128.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9128.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11326.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16989.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11326.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15856.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9128.53,16989.15,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7906.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6089.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6089.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6089.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7906.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11859.9,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7906.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11069.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6089.72,11859.9,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5546.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3992.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3992.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3992.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5546.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8319.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5546.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7764.97,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3992.26,8319.62,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9804.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7776.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7776.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7776.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9804.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14706.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9804.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13726.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7776.2,14706.56,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7431.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5667.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5667.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5667.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7431.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11147.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7431.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10403.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5667.38,11147.06,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13880.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11398.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11398.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11398.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13880.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20821.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13880.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19432.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11398.75,20821.07,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6883.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5180.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5180.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5180.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6883.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10324.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6883.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9636.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5180.34,10324.98,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4571.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3126.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3126.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3126.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4571.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6857.9,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,4571.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6400.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3126.27,6857.9,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13664.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11206.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11206.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11206.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13664.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20497.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13664.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19130.58,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11206.77,20497.05,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9590.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7586.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7586.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7586.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9590.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14386.13,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9590.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13427.05,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7586.37,14386.13,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6732.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5046.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5046.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5046.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6732.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10099.37,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6732.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9426.07,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5046.68,10099.37,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10023.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7971.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7971.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7971.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10023.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15035.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10023.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14033.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7971.03,15035.39,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6319.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4679.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4679.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4679.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6319.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9478.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6319.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8846.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4679.09,9478.92,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10246.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8169.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8169.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8169.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10246.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15370.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10246.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14345.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8169.39,15370.22,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7082.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5357.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5357.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5357.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7082.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10623.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7082.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9915.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5357.38,10623.81,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13349.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10926.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10926.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10926.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13349.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20024.21,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13349.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18689.26,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10926.65,20024.21,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8595.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6701.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6701.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6701.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8595.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12893.21,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8595.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12033.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6701.88,12893.21,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10672.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8547.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8547.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8547.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10672.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16008.66,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10672.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14941.42,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8547.64,16008.66,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7012.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5294.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5294.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5294.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7012.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10518.21,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7012.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9817,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5294.81,10518.21,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5478.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3931.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3931.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3931.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5478.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8217.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5478.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7669.77,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3931.83,8217.62,
ANGINA PECTORIS,311,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6639.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4963.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4963.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4963.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6639.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9958.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6639.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9295.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4963.49,9958.95,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7962.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6139.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6139.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6139.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7962.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11943.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7962.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11147.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6139.49,11943.92,
CHEST PAIN,313,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6843.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5144.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5144.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5144.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6843.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10264.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6843.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9580.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5144.79,10264.98,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17803.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14884.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14884.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14884.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17803.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26705.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17803.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24924.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14884.79,26705.16,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8793.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6877.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6877.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6877.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8793.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13189.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8793.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12310.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6877.51,13189.64,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6596.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6596.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9894.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6596.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9234.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4925.1,9894.15,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35952.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31013.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31013.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31013.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35952.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,53928.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,35952.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,50333.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31013.11,53928.24,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18863.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15826.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15826.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15826.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18863.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28295.28,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18863.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26408.93,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15826.86,28295.28,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24053.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20439.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20439.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20439.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24053.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36080.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24053.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33674.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20439.12,36080.34,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15642.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12964.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12964.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12964.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15642.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23463.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15642.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21899.44,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12964.38,23463.69,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34176.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29435.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29435.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29435.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34176.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51265.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,34176.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,47847.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29435.4,51265.2,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24804.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21106.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21106.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21106.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24804.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37207.25,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24804.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34726.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21106.74,37207.25,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22210.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18800.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18800.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18800.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22210.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33315.3,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22210.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31094.28,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18800.98,33315.3,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41689.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36111.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36111.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36111.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41689.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,62534.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,41689.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,58365.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36111.69,62534.16,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21034.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17756.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17756.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17756.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21034.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31552.37,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21034.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29448.87,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17756.51,31552.37,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13833.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11356.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11356.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11356.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13833.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20750.25,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13833.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19366.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11356.8,20750.25,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37191.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32114.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32114.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32114.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37191.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55787.19,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,37191.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,52068.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32114.44,55787.19,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20032.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16865.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16865.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16865.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20032.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30048.63,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20032.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28045.39,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16865.64,30048.63,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14431.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11887.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11887.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11887.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14431.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21646.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14431.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20203.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11887.92,21646.74,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30290.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25982.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25982.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25982.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30290.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45436.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30290.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42407.25,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25982.08,45436.34,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17691.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14785.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14785.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14785.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17691.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26537.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17691.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24768,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14785.25,26537.15,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13895.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11412.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11412.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11412.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13895.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20843.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13895.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19454.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11412.27,20843.87,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29656.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25418.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25418.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25418.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29656.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44484.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,29656.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,41519,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25418.25,44484.65,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17897.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14968.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14968.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14968.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17897.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26846.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17897.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25056.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14968.68,26846.76,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13026.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10639.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10639.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10639.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13026.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19539.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13026.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18236.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10639.41,19539.36,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22979.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19484.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19484.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19484.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22979.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34468.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22979.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32170.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19484.24,34468.61,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13379.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10953.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10953.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10953.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13379.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20069.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13379.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18731.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10953.66,20069.81,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11357.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9156.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9156.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9156.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11357.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17035.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11357.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15900.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9156.25,17035.95,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21448.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18124.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18124.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18124.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21448.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32172.83,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21448.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30027.97,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18124.1,32172.83,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11466.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9252.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9252.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9252.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11466.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17199.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11466.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16052.55,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9252.95,17199.17,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8861.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6937.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6937.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6937.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8861.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13291.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8861.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12405.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6937.94,13291.64,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20255.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17064.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17064.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17064.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20255.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30383.48,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20255.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28357.91,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17064.01,30383.48,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12699.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10349.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10349.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10349.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12699.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19049.72,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12699.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17779.73,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10349.32,19049.72,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9926.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7885,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7885,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7885,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9926.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14890.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9926.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13897.49,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7885,14890.17,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24450.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20791.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20791.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20791.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24450.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36675.6,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24450.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34230.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20791.77,36675.6,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14797.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12213.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12213.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12213.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14797.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22196.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14797.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20716.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12213.56,22196.39,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11955.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9688.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9688.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9688.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11955.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17933.63,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11955.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16738.05,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9688.09,17933.63,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35286.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30421.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30421.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30421.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35286.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,52929.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,35286.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49401.1,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30421.55,52929.75,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18629.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15619.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15619.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15619.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18629.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27944.85,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18629.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26081.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15619.25,27944.85,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11303.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9108.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9108.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9108.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11303.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16955.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11303.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15825.17,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9108.62,16955.54,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14271.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11745.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11745.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11745.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14271.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21406.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14271.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19979.6,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11745.72,21406.71,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8961.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7026.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7026.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7026.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8961.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13441.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8961.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12545.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7026.82,13441.65,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7004.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5287.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5287.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5287.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7004.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10506.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7004.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9805.78,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5287.71,10506.2,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15036.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12426.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12426.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12426.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15036.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22555.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15036.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21051.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12426.15,22555.22,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9393.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7410.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7410.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7410.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9393.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14089.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9393.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13150.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7410.75,14089.71,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6786.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5094.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5094.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5094.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6786.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10179.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6786.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9501.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5094.31,10179.78,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17847.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14923.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14923.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14923.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17847.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26771.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17847.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24986.42,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14923.89,26771.16,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10641.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8519.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8519.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8519.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10641.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15961.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10641.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14897.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8519.92,15961.86,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8185.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6337.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6337.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6337.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8185.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12278.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8185.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11460.18,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6337.86,12278.76,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15377.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12729.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12729.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12729.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15377.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23066.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15377.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21528.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12729.04,23066.46,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6994.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6994.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6994.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13387.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8925.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12495.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6994.81,13387.65,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6120.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4502.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4502.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4502.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6120.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9180.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6120.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8568.08,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4502.05,9180.09,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16643.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13853.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13853.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13853.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16643.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24965.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16643.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23300.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13853.83,24965.01,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9638.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7629.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7629.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7629.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9638.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14458.13,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9638.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13494.25,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7629.02,14458.13,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7111.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5382.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5382.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5382.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7111.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10667.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7111.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9955.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5382.98,10667.01,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12240.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9941.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9941.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9941.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12240.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18360.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12240.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17136.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9941.2,18360.86,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8060.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6226.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6226.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6226.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8060.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12090.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8060.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11284.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6226.23,12090.35,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13590.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11140.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11140.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11140.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13590.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20385.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13590.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19026.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11140.66,20385.44,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8827.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6908.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6908.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6908.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8827.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13241.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8827.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12358.49,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6908.07,13241.24,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6527.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4863.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4863.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4863.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6527.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9790.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6527.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9138.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4863.95,9790.95,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12683.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10334.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10334.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10334.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12683.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19024.52,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12683.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17756.21,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10334.39,19024.52,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7425.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5662.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5662.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5662.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7425.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11138.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7425.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10396.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5662.41,11138.64,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5526.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3974.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3974.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3974.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5526.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8289.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5526.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7736.97,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3974.48,8289.62,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11260.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9070.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9070.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9070.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11260.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16890.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11260.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15764.69,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9070.22,16890.74,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7339.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5585.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5585.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5585.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7339.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11009.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7339.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10275.1,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5585.62,11009.04,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14011.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11515.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11515.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11515.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14011.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21017.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14011.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19616.69,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11515.35,21017.88,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8549.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6661.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6661.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6661.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8549.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12824.79,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8549.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11969.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6661.36,12824.79,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6234.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4603.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4603.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4603.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6234.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9351.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6234.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8728.26,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4603.73,9351.71,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19028.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15973.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15973.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15973.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19028.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28542.51,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19028.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26639.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15973.32,28542.51,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13161.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10759.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10759.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10759.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13161.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19742.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13161.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18426.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10759.56,19742.18,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9959.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7914.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7914.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7914.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9959.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14939.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9959.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13943.43,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7914.15,14939.39,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45099.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39141.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39141.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39141.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45099.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,67649,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,45099.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,63139.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39141.97,67649,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24155.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20529.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20529.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20529.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24155.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36232.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24155.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33817.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20529.42,36232.74,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18263.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15293.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15293.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15293.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18263.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27395.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18263.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25568.87,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15293.62,27395.22,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30834.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26464.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26464.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26464.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30834.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46251.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30834.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43167.78,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26464.84,46251.2,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16713.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13916.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13916.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13916.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16713.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25070.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16713.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23399.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13916.4,25070.61,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13576.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11128.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11128.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11128.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13576.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20365.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13576.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19007.37,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11128.57,20365.04,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25379.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21617.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21617.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21617.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25379.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38068.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25379.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35530.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21617.24,38068.92,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17584.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14689.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14689.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14689.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17584.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26376.33,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17584.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24617.91,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14689.96,26376.33,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13131.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10733.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10733.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10733.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13131.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19697.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13131.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18384.59,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10733.26,19697.78,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29258,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25064.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25064.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25064.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29258,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43887,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,29258,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40961.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25064.17,43887,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16861.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14047.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14047.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14047.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16861.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25292.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16861.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23606.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14047.94,25292.64,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11768.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9521.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9521.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9521.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11768.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17652.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11768.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16475.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9521.71,17652.81,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19598,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16479.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16479.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16479.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19598,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29397,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19598,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27437.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16479.55,29397,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14132.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11622.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11622.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11622.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14132.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21199.1,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14132.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19785.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11622.71,21199.1,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11560.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9336.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9336.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9336.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11560.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17340.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11560.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16184.73,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9336.86,17340.78,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26662.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22757.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22757.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22757.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26662.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39993.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26662.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37327.61,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22757.69,39993.87,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14731.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12155.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12155.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12155.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14731.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22097.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14731.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20624.77,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12155.25,22097.97,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12342.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10032.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10032.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10032.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12342.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18514.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12342.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17280.19,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10032.22,18514.49,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32343.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27806.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27806.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27806.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32343.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48515.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,32343.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45281.39,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27806.49,48515.78,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18109.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15156.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15156.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15156.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18109.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27163.59,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18109.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25352.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15156.38,27163.59,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13870.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11389.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11389.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11389.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13870.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20805.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13870.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19418.43,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11389.5,20805.47,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16383.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13622.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13622.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13622.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16383.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24574.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16383.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22936.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13622.76,24574.97,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9302.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7330.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7330.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7330.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9302.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13954.08,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9302.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13023.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7330.42,13954.08,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6410.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4760.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4760.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4760.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6410.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9615.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6410.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8974.69,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4760.15,9615.74,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15134.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12512.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12512.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12512.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15134.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22701.63,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15134.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21188.19,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12512.89,22701.63,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9860.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7825.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7825.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7825.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9860.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14790.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9860.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13804.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7825.98,14790.57,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7703.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5909.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5909.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5909.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7703.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11555.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7703.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10784.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5909.12,11555.09,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14405.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11865.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11865.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11865.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14405.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21608.33,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14405.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20167.77,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11865.16,21608.33,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7896.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6080.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6080.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6080.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7896.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11844.32,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7896.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11054.69,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6080.48,11844.32,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5979.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4376.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4376.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4376.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5979.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8968.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5979.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8370.95,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4376.92,8968.88,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15680.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12998.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12998.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12998.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15680.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23521.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15680.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21953.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12998.5,23521.29,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8666.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6765.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6765.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6765.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8666.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13000.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8666.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12133.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6765.17,13000.01,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6772.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5081.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5081.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5081.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6772.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10158.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6772.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9480.95,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5081.52,10158.17,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14120.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11612.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11612.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11612.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14120.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21181.11,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14120.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19769.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11612.05,21181.11,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9749.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7727.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7727.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7727.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9749.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14623.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9749.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13648.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7727.15,14623.74,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7466.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5698.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5698.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5698.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7466.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11199.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7466.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10453.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5698.66,11199.86,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,71951.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,63004.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,63004.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,63004.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,71951.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,107926.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,71951.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,100731.64,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,63004.56,107926.76,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49988.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43486.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43486.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43486.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49988.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,74982.8,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,49988.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,69983.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43486.9,74982.8,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37901.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32745.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32745.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32745.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37901.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56852.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,37901.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,53062.67,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32745.82,56852.87,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,68494.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,59933.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,59933.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,59933.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,68494.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,102742.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,68494.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,95892.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,59933.03,102742.34,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49660.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43195.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43195.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43195.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49660.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,74490.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,49660.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,69524.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43195.38,74490.75,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37305.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32215.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32215.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32215.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37305.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55957.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,37305.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,52227.1,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32215.41,55957.61,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,54116.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,47155.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,47155.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,47155.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,54116.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,81175.32,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,54116.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,75763.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,47155.65,81175.32,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30319.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26007.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26007.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26007.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30319.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45479.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30319.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42447.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26007.67,45479.54,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55606.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48479.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48479.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48479.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55606.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,83409.9,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,55606.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,77849.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48479.54,83409.9,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23826.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20237.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20237.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20237.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23826.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35739.53,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23826.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33356.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20237.19,35739.53,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46367.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40268.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40268.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40268.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46367.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,69551.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,46367.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,64914.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40268.9,69551.15,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25067.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21339.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21339.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21339.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25067.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37600.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25067.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35094.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21339.95,37600.88,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16021.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13301.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13301.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13301.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16021.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24032.55,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16021.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22430.38,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13301.39,24032.55,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42550.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36876.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36876.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36876.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42550.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,63825.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,42550.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,59570.43,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36876.73,63825.47,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28946.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24787.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24787.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24787.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28946.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43420.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28946.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40525.49,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24787.59,43420.17,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22412.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18980.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18980.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18980.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22412.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33618.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22412.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31377.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18980.85,33618.95,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27694.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23674.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23674.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23674.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27694.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41541.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27694.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38772.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23674.88,41541.99,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16108.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13378.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13378.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13378.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16108.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24163.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16108.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22552.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13378.89,24163.35,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40409.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34974.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34974.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34974.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40409.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,60614.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,40409.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,56573.08,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34974.09,60614.01,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24699.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21012.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21012.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21012.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24699.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37048.82,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24699.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34578.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21012.89,37048.82,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20740.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17494.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17494.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17494.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20740.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31110.72,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20740.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29036.67,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17494.86,31110.72,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35479.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30592.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30592.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30592.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35479.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,53218.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,35479.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49671.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30592.91,53218.97,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18213.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15248.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15248.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15248.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18213.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27319.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18213.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25498.31,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15248.82,27319.62,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10470.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8367.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8367.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8367.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10470.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15705.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10470.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14658.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8367.76,15705.05,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28008.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23953.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23953.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23953.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28008.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42012.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28008.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39211.61,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23953.58,42012.44,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20125.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16948.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16948.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16948.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20125.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30187.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20125.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28175.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16948.1,30187.86,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15967.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13253.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13253.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13253.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15967.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23950.94,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15967.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22354.21,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13253.05,23950.94,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24647.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20966.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20966.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20966.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24647.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36970.82,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24647.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34506.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20966.67,36970.82,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17654.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14752.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14752.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14752.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17654.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26481.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17654.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24716.48,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14752.54,26481.95,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13762.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11293.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11293.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11293.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13762.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20643.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13762.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19267.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11293.52,20643.45,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20929.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17662.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17662.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17662.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20929.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31393.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20929.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29301.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17662.67,31393.95,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27408.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23420.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23420.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23420.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27408.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41112.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27408.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38371.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23420.34,41112.36,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17121.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14279.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14279.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14279.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17121.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25682.67,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17121.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23970.49,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14279.01,25682.67,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13414.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10984.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10984.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10984.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13414.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20121.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13414.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18779.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10984.24,20121.39,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17908.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14977.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14977.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14977.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17908.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26862.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17908.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25071.55,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14977.92,26862.38,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10956.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8800.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8800.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8800.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10956.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16434.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10956.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15339.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8800.04,16434.69,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28753.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24615.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24615.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24615.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28753.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43129.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28753.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40254.42,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24615.53,43129.74,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20269.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17076.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17076.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17076.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20269.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30403.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20269.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28376.95,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17076.08,30403.88,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16008.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13290.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13290.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13290.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16008.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24013.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16008.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22412.45,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13290.01,24013.34,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29706.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25462.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25462.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25462.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29706.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44559.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,29706.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,41588.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25462.32,44559.06,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16955.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14131.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14131.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14131.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16955.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25433.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16955.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23737.5,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14131.12,25433.04,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12474.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10148.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10148.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10148.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12474.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18711.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12474.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17463.87,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10148.81,18711.29,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21943.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18564.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18564.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18564.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21943.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32915.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21943.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30721.31,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18564.21,32915.69,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11373.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9170.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9170.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9170.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11373.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17059.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11373.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15922.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9170.48,17059.95,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26998.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23056.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23056.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23056.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26998.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40497.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26998.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37798.05,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23056.32,40497.92,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14940.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12340.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12340.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12340.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14940.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22411.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14940.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20917.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12340.83,22411.2,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12116.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9831,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9831,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9831,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12116.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18174.84,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12116.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16963.18,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9831,18174.84,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22511.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19068.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19068.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19068.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22511.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33766.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22511.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31515.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19068.31,33766.56,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14871.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12279.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12279.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12279.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14871.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22307.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14871.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20820.79,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12279.69,22307.99,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14700.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12127.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12127.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12127.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14700.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22051.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14700.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20581.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12127.53,22051.17,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12755.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10399.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10399.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10399.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12755.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19133.72,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12755.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17858.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10399.08,19133.72,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18109.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15156.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15156.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15156.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18109.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27163.59,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18109.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25352.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15156.38,27163.59,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12527,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10195.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10195.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10195.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12527,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18790.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12527,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17537.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10195.74,18790.5,
ARTHROSCOPY,509,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11983.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9712.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9712.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9712.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11983.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17975.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11983.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16777.26,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9712.97,17975.64,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22820.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19343.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19343.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19343.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22820.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34230.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22820.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31948.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19343.46,34230.99,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17005.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14175.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14175.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14175.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17005.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25508.66,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17005.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23808.08,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14175.91,25508.66,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13965.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11474.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11474.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11474.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13965.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20948.28,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13965.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19551.73,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11474.13,20948.28,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14023.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11525.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11525.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11525.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14023.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21034.68,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14023.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19632.37,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11525.31,21034.68,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9386.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7405.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7405.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7405.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9386.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14080.11,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9386.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13141.44,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7405.07,14080.11,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26348.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22478.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22478.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22478.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26348.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39522.23,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26348.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36887.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22478.26,39522.23,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17381.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14510.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14510.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14510.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17381.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26072.7,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17381.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24334.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14510.09,26072.7,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13010.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10625.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10625.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10625.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13010.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19515.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13010.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18214.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10625.18,19515.36,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30270.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25964.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25964.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25964.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30270.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45406.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30270.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42379.25,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25964.3,45406.34,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16804.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13996.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13996.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13996.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16804.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25206.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16804.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23525.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13996.75,25206.24,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12507,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10177.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10177.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10177.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12507,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18760.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12507,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17509.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10177.97,18760.5,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25009.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21288.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21288.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21288.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25009.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37514.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25009.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35013.5,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21288.76,37514.46,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17953.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15017.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15017.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15017.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17953.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26929.58,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17953.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25134.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15017.73,26929.58,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14106.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11599.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11599.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11599.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14106.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21159.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14106.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19748.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11599.26,21159.5,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7534.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5759.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5759.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5759.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7534.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11301.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7534.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10548.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5759.1,11301.87,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11428.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9219.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9219.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9219.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11428.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17142.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11428.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15999.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9219.54,17142.75,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7351.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5596.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5596.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5596.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7351.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11027.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7351.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10291.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5596.28,11027.04,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8790.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6875.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6875.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6875.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8790.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13186.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8790.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12306.97,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6875.37,13186.04,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6727.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5041.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5041.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5041.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6727.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10090.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6727.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9418.23,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5041.7,10090.97,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16930.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14109.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14109.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14109.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16930.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25395.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16930.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23702.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14109.09,25395.86,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11440.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9230.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9230.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9230.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11440.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17160.77,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11440.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16016.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9230.21,17160.77,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7917.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6099.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6099.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6099.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7917.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11876.72,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7917.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11084.93,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6099.67,11876.72,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15644.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12966.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12966.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12966.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15644.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23467.28,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15644.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21902.79,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12966.51,23467.28,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9780.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7754.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7754.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7754.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9780.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14670.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9780.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13692.5,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7754.87,14670.54,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7194.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5456.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5456.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5456.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7194.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10791.84,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7194.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10072.38,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5456.93,10791.84,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21001.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17726.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17726.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17726.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21001.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31501.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21001.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29401.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17726.65,31501.97,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10649.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8527.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8527.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8527.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10649.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15973.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10649.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14908.95,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8527.02,15973.88,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7640.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5853.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5853.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5853.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7640.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11461.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7640.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10697.39,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5853.67,11461.49,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16653.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13863.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13863.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13863.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16653.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24980.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16653.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23315.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13863.07,24980.61,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10704.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8576.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8576.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8576.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10704.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16056.68,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10704.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14986.23,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8576.07,16056.68,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8602.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6708.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6708.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6708.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8602.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12904.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8602.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12043.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6708.28,12904.01,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14670.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12100.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12100.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12100.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14670.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22005.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14670.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20538.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12100.5,22005.56,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8785.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6870.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6870.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6870.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8785.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13177.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8785.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12299.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6870.4,13177.64,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11866.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9609.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9609.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9609.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11866.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17800.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11866.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16613.72,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9609.16,17800.41,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7628.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5843,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5843,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5843,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7628.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11443.49,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7628.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10680.59,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5843,11443.49,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12246.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9946.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9946.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9946.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12246.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18370.46,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12246.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17145.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9946.88,18370.46,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7649.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5861.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5861.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5861.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7649.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11474.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7649.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10709.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5861.48,11474.69,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13509.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11068.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11068.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11068.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13509.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20264.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13509.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18913.29,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11068.85,20264.24,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8081.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6245.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6245.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6245.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8081.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12122.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8081.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11314.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6245.43,12122.75,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15859.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13157.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13157.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13157.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15859.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23788.91,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15859.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22202.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13157.06,23788.91,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10111.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8049.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8049.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8049.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10111.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15167.4,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10111.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14156.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8049.23,15167.4,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7296.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5547.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5547.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5547.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7296.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10944.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7296.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10214.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5547.22,10944.24,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13220.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10812.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10812.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10812.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13220.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19830.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13220.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18508.92,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10812.18,19830.99,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8219.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6367.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6367.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6367.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8219.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12329.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8219.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11507.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6367.72,12329.16,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13550.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11105.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11105.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11105.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13550.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20325.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13550.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18970.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11105.11,20325.44,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9049.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7105.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7105.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7105.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9049.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13574.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9049.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12669.87,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7105.74,13574.87,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7058.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5336.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5336.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5336.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7058.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10587.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7058.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9881.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5336.05,10587.81,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24433.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20776.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20776.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20776.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24433.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36650.4,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24433.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34207.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20776.84,36650.4,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14590.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12029.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12029.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12029.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14590.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21885.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14590.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20426.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12029.41,21885.57,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10171.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8102.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8102.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8102.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10171.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15257.4,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10171.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14240.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8102.55,15257.4,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50803,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44210.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44210.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44210.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50803,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,76204.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,50803,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,71124.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44210.68,76204.5,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28302.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24215.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24215.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24215.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28302.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42454.08,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28302.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39623.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24215.24,42454.08,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17423.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14547.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14547.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14547.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17423.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26135.1,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17423.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24392.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14547.07,26135.1,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46522.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40406.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40406.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40406.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46522.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,69783.96,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,46522.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,65131.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40406.84,69783.96,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22248.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18835.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18835.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18835.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22248.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33372.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22248.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31148.05,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18835.1,33372.92,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13939.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11450.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11450.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13939.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20908.68,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13939.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19514.77,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11450.65,20908.68,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27793.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23763.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23763.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23763.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27793.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41690.82,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27793.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38911.43,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23763.04,41690.82,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15028.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12418.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12418.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12418.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15028.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22542.02,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15028.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21039.21,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12418.33,22542.02,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11828.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9575.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9575.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9575.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11828.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17742.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11828.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16559.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9575.03,17742.81,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14985.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12380.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12380.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12380.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14985.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22478.4,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14985.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20979.84,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12380.65,22478.4,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13230.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10820.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10820.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10820.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13230.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19845.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13230.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18522.35,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10820.71,19845.38,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16724.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13925.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13925.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13925.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16724.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25086.23,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16724.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23413.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13925.64,25086.23,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14527.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11973.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11973.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11973.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14527.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21790.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14527.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20338.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11973.23,21790.76,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17776.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14860.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14860.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14860.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17776.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26664.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17776.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24886.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14860.6,26664.36,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10734.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8602.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8602.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8602.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10734.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16101.08,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10734.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15027.67,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8602.38,16101.08,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7353.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5598.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5598.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5598.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7353.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11030.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7353.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10295.26,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5598.41,11030.64,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18455.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15464.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15464.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15464.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18455.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27683.25,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18455.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25837.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15464.25,27683.25,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9126.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7174,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7174,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7174,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9126.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13690.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9126.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12777.39,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7174,13690.07,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13859.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11379.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11379.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11379.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13859.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20788.67,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13859.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19402.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11379.55,20788.67,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10645.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8523.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8523.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8523.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10645.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15967.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10645.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14903.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8523.47,15967.86,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6436.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4783.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4783.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4783.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6436.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9655.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6436.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9011.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4783.61,9655.34,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9258.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7291.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7291.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7291.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9258.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13888.08,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9258.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12962.21,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7291.3,13888.08,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6122.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4504.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4504.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4504.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6122.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9183.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6122.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8571.44,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4504.18,9183.69,
CELLULITIS WITH MCC,602,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12955.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10576.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10576.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10576.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12955.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19432.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12955.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18137.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10576.13,19432.56,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8132.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6290.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6290.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6290.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8132.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12198.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8132.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11385.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6290.22,12198.36,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13104.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10709.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10709.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10709.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13104.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19656.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13104.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18346.51,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10709.08,19656.98,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8325.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6461.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6461.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6461.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8325.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12487.58,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8325.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11655.07,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6461.57,12487.58,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13741.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11275.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11275.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11275.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13741.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20612.25,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13741.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19238.1,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11275.03,20612.25,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8202.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6352.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6352.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6352.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8202.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12303.96,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8202.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11483.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6352.79,12303.96,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19074.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16014.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16014.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16014.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19074.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28612.13,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19074.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26704.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16014.57,28612.13,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12823.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10459.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10459.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10459.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12823.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19235.73,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12823.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17953.35,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10459.52,19235.73,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32718.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28139.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28139.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28139.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32718.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49077.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,32718.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45805.61,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28139.24,49077.44,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16931.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14109.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14109.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14109.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16931.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25397.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16931.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23703.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14109.8,25397.04,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10346.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8258.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8258.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8258.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10346.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15520.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10346.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14485.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8258.27,15520.22,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21875.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18503.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18503.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18503.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21875.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32813.67,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21875.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30626.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18503.78,32813.67,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14032.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11533.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11533.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11533.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14032.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21049.08,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14032.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19645.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11533.85,21049.08,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10788.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10788.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10788.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19790.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18470.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10788.01,19790.18,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31661.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27200.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27200.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27200.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31661.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,47492.1,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,31661.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44325.96,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27200.01,47492.1,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15946.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13234.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13234.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13234.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15946.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23919.72,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15946.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22325.07,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13234.55,23919.72,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9970.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7924.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7924.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7924.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9970.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14956.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9970.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13959.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7924.09,14956.17,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24425.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20769.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20769.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20769.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24425.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36638.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24425.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34195.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20769.73,36638.39,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12990.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10607.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10607.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10607.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12990.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19485.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12990.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18186.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10607.4,19485.36,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10942.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8787.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8787.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8787.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10942.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16414.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10942.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15320,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8787.96,16414.29,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33172.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28543.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28543.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28543.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33172.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49759.1,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,33172.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,46441.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28543.1,49759.1,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19157.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16088.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16088.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16088.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19157.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28736.93,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19157.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26821.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16088.51,28736.93,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12225.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9927.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9927.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9927.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12225.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18338.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12225.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17115.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9927.69,18338.06,
DIABETES WITH MCC,637,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12649.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10304.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10304.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10304.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12649.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18974.1,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12649.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17709.16,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10304.52,18974.1,
DIABETES WITH CC,638,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8249.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6394.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6394.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6394.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8249.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12374.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8249.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11549.79,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6394.74,12374.78,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6034.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4425.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4425.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4425.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6034.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9051.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6034.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8448.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4425.97,9051.69,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11576.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9351.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9351.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9351.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11576.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17364.77,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11576.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16207.11,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9351.07,17364.77,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7305.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5555.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5555.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5555.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7305.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10958.63,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7305.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10228.05,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5555.76,10958.63,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11481.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9266.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9266.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9266.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11481.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17221.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11481.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16073.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9266.47,17221.97,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14215.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11696.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11696.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11696.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14215.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21323.91,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14215.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19902.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11696.66,21323.91,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9548.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7548.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7548.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7548.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9548.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14322.53,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9548.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13367.69,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7548.69,14322.53,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7141.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5410,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5410,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5410,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7141.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10712.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7141.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9998.44,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5410,10712.61,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37037.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31977.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31977.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31977.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37037.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55555.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,37037.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,51851.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31977.23,55555.56,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28723.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24589.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24589.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24589.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28723.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43085.33,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28723.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,40212.97,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24589.22,43085.33,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25091.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21361.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21361.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21361.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25091.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37636.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25091.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35127.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21361.29,37636.88,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44366.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38490.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38490.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,38490.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44366.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,66549.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,44366.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,62113.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38490.69,66549.69,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22955.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19463.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19463.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19463.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22955.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34433.79,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22955.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32138.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19463.62,34433.79,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17917.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14986.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14986.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14986.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17917.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26876.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17917.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25084.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14986.46,26876.78,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26156.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22308.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22308.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22308.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26156.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39235.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26156.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36619.72,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22308.34,39235.41,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15808.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13112.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13112.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13112.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15808.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23713.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15808.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22132.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13112.27,23713.29,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12898.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10525.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10525.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10525.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12898.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19347.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12898.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18057.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10525.65,19347.35,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21766.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18407.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18407.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18407.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21766.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32650.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21766.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30473.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18407.08,32650.44,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11822.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9569.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9569.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9569.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11822.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17733.23,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11822.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16551.01,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9569.35,17733.23,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9441.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7454.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7454.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7454.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9441.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14162.91,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9441.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13218.72,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7454.12,14162.91,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25029.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21306.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21306.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21306.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25029.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37544.48,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25029.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35041.51,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21306.54,37544.48,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12727.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10373.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10373.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10373.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12727.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19090.52,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12727.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17817.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10373.49,19090.52,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9547.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7547.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7547.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7547.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9547.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14321.31,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9547.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13366.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7547.98,14321.31,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25768.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21963.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21963.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21963.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25768.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38653.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25768.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36076.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21963.49,38653.35,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14794.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12210.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12210.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12210.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14794.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22191.59,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14794.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20712.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12210.71,22191.59,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9451.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7462.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7462.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7462.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9451.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14177.33,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9451.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13232.17,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7462.67,14177.33,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23599.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20035.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20035.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20035.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23599.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35399.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23599.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33039.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20035.98,35399.88,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13331.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10911,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10911,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10911,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13331.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19997.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13331.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18664.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10911,19997.81,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8755.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6844.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6844.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6844.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8755.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13133.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8755.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12257.69,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6844.09,13133.24,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14750.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12171.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12171.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12171.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14750.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22125.59,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14750.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20650.55,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12171.61,22125.59,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8554.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6665.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6665.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6665.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8554.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12831.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8554.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11976.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6665.62,12831.99,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30640.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26292.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26292.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26292.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30640.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45960.77,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30640.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42896.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26292.78,45960.77,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20113.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16937.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16937.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16937.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20113.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30169.85,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20113.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28158.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16937.43,30169.85,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13747.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13747.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20620.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13747.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19245.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11280.02,20620.65,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13061.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10670.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10670.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10670.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13061.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19592.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13061.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18286.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10670.69,19592.18,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8261.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6404.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6404.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6404.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8261.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12391.58,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8261.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11565.47,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6404.68,12391.58,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5922.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4326.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4326.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4326.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5922.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8883.66,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5922.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8291.42,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4326.44,8883.66,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15770.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13078.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13078.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13078.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15770.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23655.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15770.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22078.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13078.13,23655.71,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9417.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7432.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7432.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7432.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9417.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14125.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9417.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13184,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7432.08,14125.71,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7301.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5552.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5552.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5552.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7301.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10952.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7301.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10222.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5552.21,10952.64,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10450.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8349.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8349.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8349.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10450.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15675.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10450.03,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14630.04,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8349.98,15675.05,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7509.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5737.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5737.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5737.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7509.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11264.67,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7509.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10513.69,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5737.06,11264.67,
URINARY STONES WITH MCC,693,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12385.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10069.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10069.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10069.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12385.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18578.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12385.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17339.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10069.89,18578.07,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7316.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5565,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5565,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5565,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7316.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10974.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7316.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10242.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5565,10974.24,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10622.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8503.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8503.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8503.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10622.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15934.26,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10622.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14871.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8503.56,15934.26,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6591.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4920.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4920.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4920.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6591.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9886.95,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6591.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9227.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4920.83,9886.95,
URETHRAL STRICTURE,697,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9959.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7914.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7914.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7914.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9959.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14939.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9959.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13943.43,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7914.15,14939.39,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14290.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11762.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11762.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11762.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14290.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21435.51,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14290.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20006.48,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11762.78,21435.51,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9221.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7257.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7257.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7257.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9221.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13831.68,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9221.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12909.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7257.89,13831.68,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6720.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5036.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5036.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5036.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6720.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10081.37,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6720.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9409.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5036.01,10081.37,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16750.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13949.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13949.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13949.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16750.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25125.83,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16750.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23450.77,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13949.1,25125.83,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12723.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10369.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10369.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10369.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12723.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19084.52,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12723.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17812.21,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10369.94,19084.52,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18421.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15434.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15434.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15434.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18421.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27632.84,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18421.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25790.65,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15434.39,27632.84,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11433.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9223.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9223.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9223.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11433.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17149.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11433.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16006.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9223.81,17149.97,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18038.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15093.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15093.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15093.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18038.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27057.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18038.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25254.12,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15093.82,27057.99,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10562.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8449.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8449.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8449.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10562.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15843.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10562.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14786.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8449.53,15843.06,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12660.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10314.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10314.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10314.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12660.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18990.9,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12660.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17724.84,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10314.48,18990.9,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8722.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6814.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6814.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6814.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8722.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13084.02,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8722.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12211.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6814.93,13084.02,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18715.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15695.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15695.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15695.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18715.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28073.28,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18715.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26201.73,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15695.32,28073.28,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12432.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10111.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10111.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10111.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12432.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18648.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12432.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17405.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10111.84,18648.89,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15564.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12895.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12895.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12895.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15564.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23347.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15564.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21790.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12895.41,23347.29,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10461.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8359.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8359.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8359.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10461.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15691.85,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10461.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14645.72,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8359.93,15691.85,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16053.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13329.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13329.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13329.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16053.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24080.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16053.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22475.17,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13329.83,24080.54,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9969.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7922.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7922.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7922.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9969.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14953.77,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9969.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13956.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7922.68,14953.77,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7530.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5755.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5755.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5755.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7530.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11295.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7530.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10542.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5755.54,11295.87,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10982.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8822.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8822.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8822.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10982.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16473.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10982.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15374.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8822.8,16473.09,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6901.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5196.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5196.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5196.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6901.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10352.58,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6901.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9662.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5196.69,10352.58,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14023.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11525.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11525.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11525.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14023.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21034.68,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14023.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19632.37,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11525.31,21034.68,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7455.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5688.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5688.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5688.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7455.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11183.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7455.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10437.52,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5688.71,11183.06,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9085.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7137.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7137.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7137.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9085.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13628.87,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9085.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12720.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7137.73,13628.87,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6027.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4419.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4419.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4419.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6027.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9040.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6027.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8438.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4419.57,9040.88,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18444.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15454.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15454.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15454.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18444.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27666.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18444.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25822.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15454.3,27666.45,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11136.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8960.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8960.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8960.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11136.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16704.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11136.49,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15591.09,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8960.02,16704.74,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32154.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27638,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27638,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27638,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32154.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48231.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,32154.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,45015.95,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27638,48231.38,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16845.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14033.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14033.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14033.72,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16845.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25268.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16845.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23584.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14033.72,25268.64,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11971.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9702.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9702.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9702.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11971.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17957.63,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11971.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16760.45,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9702.31,17957.63,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29986.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25711.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25711.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25711.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29986.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,44980.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,29986.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,41981.6,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25711.9,44980.29,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15351.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12705.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12705.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12705.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15351.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23026.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15351.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21491.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12705.57,23026.86,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11449.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9238.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9238.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9238.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11449.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17173.97,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11449.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16029.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9238.02,17173.97,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15310.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12669.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12669.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12669.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15310.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22965.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15310.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21434.6,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12669.31,22965.65,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10350.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8261.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8261.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8261.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10350.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15526.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10350.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14491.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8261.82,15526.22,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16114.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13383.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13383.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13383.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16114.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24171.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16114.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22560.3,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13383.87,24171.75,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9341.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7365.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7365.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7365.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9341.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14012.9,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9341.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13078.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7365.25,14012.9,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14463.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11917.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11917.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11917.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14463.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21695.94,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14463.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20249.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11917.06,21695.94,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8152.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6307.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6307.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6307.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8152.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12228.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8152.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11413.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6307.98,12228.36,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12294.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9988.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9988.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9988.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12294.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18441.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12294.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17211.87,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9988.84,18441.29,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21193.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17897.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17897.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17897.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21193.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31790,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21193.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29670.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17897.29,31790,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11934.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9669.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9669.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9669.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11934.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17902.43,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11934.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16708.93,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9669.59,17902.43,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15875.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13171.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13171.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13171.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15875.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23812.94,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15875.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22225.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13171.28,23812.94,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9732.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7712.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7712.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7712.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9732.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14598.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9732.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13625.3,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7712.22,14598.54,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8972.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7036.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7036.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7036.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8972.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13458.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8972.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12561.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7036.77,13458.45,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12987.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10605.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10605.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10605.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12987.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19481.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12987.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18182.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10605.28,19481.76,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8995.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7057.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7057.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7057.39,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8995.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13493.25,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8995.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12593.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7057.39,13493.25,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6224.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4594.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4594.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4594.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6224.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9336.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6224.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8713.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4594.48,9336.09,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9017.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7077.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7077.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7077.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9017.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13526.85,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9017.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12625.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7077.3,13526.85,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5899.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4305.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4305.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4305.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5899.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8848.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5899.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8258.95,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4305.82,8848.88,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10799.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8660.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8660.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8660.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10799.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10799.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,2500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,10799.66,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13406.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10977.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10977.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10977.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13406.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20109.42,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13406.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18768.79,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10977.13,20109.42,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7444.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5678.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5678.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5678.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7444.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11166.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7444.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10421.85,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5678.75,11166.27,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6788.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5095.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5095.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5095.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6788.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10182.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6788.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9503.35,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5095.74,10182.17,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8968.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7033.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7033.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7033.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8968.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13452.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8968.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12555.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7033.22,13452.45,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15229.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12597.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12597.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12597.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15229.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15229.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,15229.62,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9247.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7281.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7281.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7281.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9247.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9247.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,9247.52,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7985.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6159.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6159.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6159.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7985.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7985.01,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,7985.01,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15051.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12438.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12438.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12438.94,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15051.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15051.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,15051.21,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9463.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7473.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7473.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7473.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9463.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9463.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,9463.54,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7894.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6079.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6079.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6079.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7894.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7894.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3500,7894.61,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15610.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12935.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12935.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12935.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15610.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23415.68,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15610.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21854.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12935.93,23415.68,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49058.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42660.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42660.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42660.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49058.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,73588.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,49058.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,68682.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42660.71,73588.29,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33838.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29134.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29134.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29134.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33838.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50757.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,33838.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,47373.73,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29134.66,50757.57,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20835.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17579.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17579.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17579.47,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20835.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31253.54,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20835.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29169.97,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17579.47,31253.54,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34731.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29928.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29928.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29928.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34731.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,52096.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,34731.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48623.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29928.12,52096.88,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12974.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10593.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10593.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10593.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12974.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19461.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12974.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18163.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10593.19,19461.36,
NORMAL NEWBORN,795,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2667.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1434.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,1434.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,1434.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2667.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,400,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,2667.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3734.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,400,3734.89,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12402.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10084.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10084.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10084.83,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12402.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12402.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,2500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,12402.19,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9021.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7080.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7080.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7080.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9021.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9021.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,2500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,9021.9,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7735.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5937.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5937.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5937.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7735.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7735.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,2500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,7735.4,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40694.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35227.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35227.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35227.21,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40694.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,61041.23,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,40694.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,56971.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35227.21,61041.23,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23597.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20033.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20033.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20033.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23597.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35396.28,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23597.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33036.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20033.85,35396.28,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15372.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12724.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12724.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12724.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15372.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23059.26,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15372.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21521.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12724.76,23059.26,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28502.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24392.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24392.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24392.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28502.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42754.1,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28502.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39903.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24392.99,42754.1,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15920.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13211.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13211.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13211.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15920.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23881.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15920.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22289.25,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13211.8,23881.34,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10738.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8605.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8605.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8605.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10738.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16107.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10738.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15033.26,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8605.95,16107.06,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9120.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7168.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7168.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7168.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9120.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9120.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,2500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,9120.31,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7028.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5309.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5309.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5309.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7028.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7028.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,2500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,7028.14,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6288.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4652.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4652.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4652.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6288.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6288.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,2500,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,2500,6288.88,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18576.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15571.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15571.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15571.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18576.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27864.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18576.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26006.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15571.62,27864.45,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10690.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8563.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8563.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8563.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10690.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16035.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10690.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14966.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8563.29,16035.06,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9090.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7141.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7141.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7141.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9090.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13636.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9090.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12726.98,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7141.99,13636.05,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12283.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9979.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9979.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9979.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12283.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18425.67,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12283.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17197.29,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9979.6,18425.67,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8260.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6403.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6403.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6403.97,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8260.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12390.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8260.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11564.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6403.97,12390.36,
COAGULATION DISORDERS,813,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13535.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11091.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11091.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11091.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13535.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20302.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13535.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18949.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11091.6,20302.64,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18080.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15130.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15130.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15130.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18080.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27120.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18080.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25312.36,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15130.79,27120.39,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9008.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7068.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7068.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7068.77,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9008.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13512.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9008.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12611.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7068.77,13512.47,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6736.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5049.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5049.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5049.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6736.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10104.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6736.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9430.55,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5049.52,10104.17,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23590.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20027.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20027.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20027.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23590.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35385.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23590.33,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33026.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20027.44,35385.5,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12503.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10175.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10175.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10175.12,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12503.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18755.7,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12503.8,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17505.32,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10175.12,18755.7,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8312.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6450.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6450.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6450.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8312.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12468.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8312.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11637.15,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6450.19,12468.38,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49431.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42992.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42992.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,42992.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49431.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,74147.52,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,49431.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,69204.35,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42992.04,74147.52,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18912.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15870.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15870.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15870.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18912.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28368.51,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18912.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26477.28,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15870.23,28368.51,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10965.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8807.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8807.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8807.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10965.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16447.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10965.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15351.36,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8807.88,16447.89,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37072.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32008.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32008.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32008.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37072.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,55608.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,37072.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,51901.16,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32008.52,55608.39,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18918.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15875.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15875.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15875.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18918.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28378.11,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18918.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26486.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15875.92,28378.11,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11386.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9181.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9181.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9181.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11386.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17079.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11386.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15940.54,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9181.86,17079.15,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38078.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32902.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32902.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32902.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38078.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,57118.11,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,38078.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,53310.24,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32902.95,57118.11,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19593.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16475.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16475.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16475.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19593.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,29389.79,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,19593.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27430.47,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16475.29,29389.79,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14178.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11663.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11663.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11663.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14178.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21267.51,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14178.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19849.68,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11663.25,21267.51,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26286.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22423.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22423.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22423.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26286.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39429.83,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26286.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36801.17,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22423.51,39429.83,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13704.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11242.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11242.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11242.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13704.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20557.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13704.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19186.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11242.32,20557.04,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9657.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7645.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7645.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7645.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9657.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14485.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9657.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13520.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7645.38,14485.74,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6956.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5245.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5245.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5245.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6956.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10434.2,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6956.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9738.58,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5245.04,10434.2,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5148.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3638.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3638.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,3638.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5148.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7723.17,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5148.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7208.29,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,3638.9,7723.17,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45849.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39808.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39808.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39808.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,45849.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,68774.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,45849.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,64189.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39808.89,68774.69,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18939.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15894.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15894.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15894.4,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18939.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28409.31,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18939.54,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26515.36,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15894.4,28409.31,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12350.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10038.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10038.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10038.61,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12350.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18525.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12350.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17290.25,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10038.61,18525.27,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39809.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34440.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34440.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34440.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39809.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,59713.92,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,39809.28,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,55732.99,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34440.84,59713.92,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17068.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14232.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14232.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14232.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17068.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25603.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17068.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23896.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14232.08,25603.47,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11479.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9265.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9265.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9265.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11479.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17219.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11479.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16071.59,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9265.04,17219.57,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26057.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22220.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22220.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22220.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26057.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,39086.6,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26057.73,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,36480.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22220.17,39086.6,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13643.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11187.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11187.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11187.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13643.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20464.64,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13643.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19100.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11187.59,20464.64,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9585.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7582.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7582.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7582.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9585.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14378.93,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9585.95,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13420.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7582.11,14378.93,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15940.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13228.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13228.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13228.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15940.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23910.12,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15940.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22316.11,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13228.86,23910.12,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10312.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8227.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8227.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8227.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10312.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15468.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10312.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14437.37,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8227.69,15468.62,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7973.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6149.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6149.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6149.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7973.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11960.72,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7973.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11163.33,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6149.44,11960.72,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20607.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17376.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17376.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17376.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20607.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30911.52,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20607.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28850.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17376.84,30911.52,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10755.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8621.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8621.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8621.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10755.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16133.48,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10755.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15057.91,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8621.58,16133.48,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7744.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5945.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5945.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5945.38,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7744.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11616.3,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7744.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10841.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5945.38,11616.3,
RADIOTHERAPY,849,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22587.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19135.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19135.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19135.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22587.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33880.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22587.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31621.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19135.85,33880.56,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41051.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35545.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35545.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35545.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,41051.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,61577.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,41051.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,57472.51,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35545.02,61577.69,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17361,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14491.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14491.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14491.6,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17361,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26041.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17361,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24305.4,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14491.6,26041.5,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14669.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12099.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12099.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12099.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14669.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22004.37,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14669.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20537.41,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12099.79,22004.37,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36484.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31485.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31485.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,31485.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36484.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,54726.3,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,36484.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,51077.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31485.92,54726.3,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18141.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15184.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15184.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15184.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18141.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27211.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18141.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25397.5,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15184.82,27211.61,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11322.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9124.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9124.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9124.98,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11322.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16983.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11322.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15850.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9124.98,16983.15,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15791.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13096.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13096.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13096.63,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15791.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23686.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15791.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22107.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13096.63,23686.89,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9098.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7149.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7149.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7149.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9098.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13648.07,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9098.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12738.19,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7149.11,13648.07,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8117.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6276.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6276.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6276.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8117.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12175.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8117.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11363.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6276.71,12175.56,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14174.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11659.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11659.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11659.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14174.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21261.51,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14174.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19844.08,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11659.69,21261.51,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8396.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6524.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6524.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6524.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8396.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12594.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8396.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11754.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6524.86,12594.39,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17793.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14876.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14876.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14876.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17793.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26690.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17793.84,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24911.38,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14876.26,26690.76,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9738.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7717.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7717.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7717.91,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9738.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14608.14,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9738.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13634.26,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7717.91,14608.14,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6580.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4910.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4910.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4910.88,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6580.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9870.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6580.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9212.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4910.88,9870.15,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56777.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49520.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49520.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49520.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56777.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,85166.85,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,56777.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,79489.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49520.44,85166.85,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,7,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,99193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87214.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,87214.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,87214.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,99193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,148790.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,99193.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,138870.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,87214.09,148790.18,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9293.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7322.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7322.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7322.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9293.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13940.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9293.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13011.49,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7322.59,13940.88,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30908.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26530.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26530.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26530.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30908.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46362.8,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30908.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43271.94,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26530.96,46362.8,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8691.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6787.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6787.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6787.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8691.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13037.22,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8691.48,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12168.07,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6787.2,13037.22,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8306.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6445.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6445.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6445.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8306.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12459.98,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8306.65,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11629.31,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6445.22,12459.98,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8569.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6678.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6678.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6678.42,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8569.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12853.61,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8569.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11996.7,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6678.42,12853.61,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16058.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13334.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13334.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13334.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16058.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24087.75,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16058.5,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22481.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13334.09,24087.75,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15110.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12491.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12491.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12491.56,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15110.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22665.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15110.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21154.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12491.56,22665.62,
PSYCHOSES,885,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11986.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9715.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9715.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9715.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11986.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17979.24,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11986.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16780.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9715.1,17979.24,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14508.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11956.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11956.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11956.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14508.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21763.14,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14508.76,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20312.26,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11956.89,21763.14,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11419.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9211.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9211.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9211.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11419.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17129.55,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11419.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15987.58,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9211.71,17129.55,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5650.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4084.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4084.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4084.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5650.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8475.65,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5650.43,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7910.6,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4084.7,8475.65,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13925.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11438.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11438.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11438.58,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13925.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20888.27,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13925.51,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19495.71,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11438.58,20888.27,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12642.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12642.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12642.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22920.03,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15280.02,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21392.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12642.29,22920.03,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7899.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6083.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6083.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6083.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7899.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11849.12,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7899.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11059.17,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6083.31,11849.12,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35679.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30770.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30770.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,30770.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,35679.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,53519.01,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,35679.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49951.08,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30770.66,53519.01,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16132.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13400.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13400.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13400.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16132.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24199.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16132.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22586.06,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13400.22,24199.35,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10986.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8827.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8827.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8827.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10986.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16480.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,10986.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15381.6,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8827.06,16480.29,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27105.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23151.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23151.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23151.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27105.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40658.72,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,27105.81,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37948.13,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23151.59,40658.72,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13724.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11260.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11260.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11260.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13724.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20587.04,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13724.69,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19214.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11260.11,20587.04,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16108.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13378.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13378.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13378.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16108.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24162.15,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,16108.1,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22551.34,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13378.18,24162.15,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30812.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26445.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26445.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,26445.64,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,30812.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,46218.78,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,30812.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43137.53,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26445.64,46218.78,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17088.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14249.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14249.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14249.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17088.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25632.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17088.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,23923.47,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14249.15,25632.29,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11905.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9643.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9643.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9643.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11905.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17858.03,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11905.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16667.49,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9643.29,17858.03,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13011.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10625.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10625.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10625.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13011.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19516.56,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13011.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18215.46,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10625.89,19516.56,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8316.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6453.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6453.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6453.75,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8316.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12474.38,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8316.25,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11642.75,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6453.75,12474.38,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15247.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12613.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12613.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12613.13,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15247.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22870.83,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15247.22,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21346.11,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12613.13,22870.83,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6324.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4684.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4684.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4684.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6324.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9487.31,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6324.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8854.82,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4684.08,9487.31,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13822.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11346.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11346.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11346.85,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13822.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20733.45,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13822.3,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19351.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11346.85,20733.45,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7941.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6121,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6121,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6121,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7941.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11912.73,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7941.82,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11118.55,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6121,11912.73,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15652.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12973.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12973.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12973.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15652.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23479.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15652.86,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21914,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12973.62,23479.29,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9325.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7350.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7350.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7350.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9325.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13987.71,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9325.14,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13055.2,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7350.32,13987.71,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6636.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4961.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4961.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4961.37,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6636.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9955.35,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6636.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9291.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4961.37,9955.35,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15014.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12406.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12406.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12406.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15014.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22521.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15014.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21020.17,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12406.24,22521.62,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9145.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7191.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7191.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7191.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9145.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13718.88,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9145.92,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12804.29,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7191.05,13718.88,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,211941.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,187410.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,187410.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,187410.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,211941.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,317911.94,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,211941.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,296717.81,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,187410.35,317911.94,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56416.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49199.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49199.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,49199.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56416.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,84624.39,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,56416.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,78982.76,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49199.07,84624.39,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26780.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22862.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22862.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22862.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26780.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40170.29,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26780.19,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37492.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22862.2,40170.29,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25312.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21557.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21557.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,21557.52,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,25312.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,37968.09,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,25312.06,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,35436.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21557.52,37968.09,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17795.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14877.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14877.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14877.68,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17795.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26693.18,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17795.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24913.63,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14877.68,26693.18,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17384.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14512.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14512.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,14512.23,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17384.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26076.3,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,17384.2,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24337.88,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14512.23,26076.3,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26778.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22860.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22860.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22860.78,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,26778.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,40167.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,26778.59,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,37490.03,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22860.78,40167.89,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18388.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15404.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15404.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15404.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18388.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27582.44,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,18388.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,25743.61,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15404.53,27582.44,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15903.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13196.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13196.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13196.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,15903.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23854.94,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,15903.29,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,22264.61,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13196.16,23854.94,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13131.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10732.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10732.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10732.55,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13131.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19696.58,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13131.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18383.47,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10732.55,19696.58,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9156.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7200.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7200.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7200.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9156.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13734.47,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9156.31,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12818.83,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7200.31,13734.47,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11067.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8898.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8898.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8898.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11067.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,16601.51,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11067.67,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,15494.74,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8898.87,16601.51,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7462.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5695.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5695.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,5695.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7462.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11193.86,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7462.57,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10447.6,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5695.11,11193.86,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9637.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7627.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7627.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7627.62,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9637.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14455.73,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9637.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13492.01,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7627.62,14455.73,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6163.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4540.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4540.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4540.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6163.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9244.89,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,6163.26,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8628.56,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4540.44,9244.89,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5774.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4194.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4194.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,4194.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,5774.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8661.66,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,5774.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,8084.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,4194.9,8661.66,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49779.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43301.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43301.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,43301.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,49779.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,74669.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,49779.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,69691.59,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,43301.32,74669.57,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32082.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27574,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27574,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,27574,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,32082.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48123.36,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,32082.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,44915.14,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,27574,48123.36,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,58918.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51423.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,51423.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,51423.08,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,58918.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,88378.34,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,58918.89,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,82486.45,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,51423.08,88378.34,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33415.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28758.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28758.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,28758.53,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33415.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,50122.73,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,33415.15,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,46781.21,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28758.53,50122.73,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21314.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18005.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18005.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18005.36,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21314.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31972.4,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,21314.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29840.9,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18005.36,31972.4,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22930.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19440.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19440.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19440.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,22930.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34395.41,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,22930.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32102.38,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19440.87,34395.41,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13063.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10672.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10672.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10672.11,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13063.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19594.58,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,13063.05,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,18288.27,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10672.11,19594.58,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8701.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6796.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6796.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6796.45,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,8701.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,13052.81,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,8701.87,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12182.62,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6796.45,13052.81,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56039.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48864.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48864.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,48864.18,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,56039.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,84059.16,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,56039.44,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,78455.22,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,48864.18,84059.16,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23292.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19762.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19762.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19762.96,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,23292.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,34939.05,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,23292.7,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,32609.78,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,19762.96,34939.05,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24387.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20736.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20736.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20736.32,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24387.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,36581.99,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,24387.99,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,34143.19,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20736.32,36581.99,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11961.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9693.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9693.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,9693.07,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11961.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17942.03,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,11961.35,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,16745.89,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9693.07,17942.03,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7817,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6010.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6010.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,6010.09,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7817,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11725.5,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,7817,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10943.8,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,6010.09,11725.5,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12383.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10068.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10068.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,10068.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12383.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,18575.69,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,12383.79,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17337.31,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,10068.46,18575.69,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38980.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33704.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33704.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,33704.24,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,38980.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,58470.62,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,38980.41,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,54572.57,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,33704.24,58470.62,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20943.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17675.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17675.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,17675.46,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,20943.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,31415.57,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,20943.71,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,29321.19,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,17675.46,31415.57,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14136.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11626.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11626.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,11626.27,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14136.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21205.11,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14136.74,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,19791.44,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,11626.27,21205.11,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28069.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24008.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24008.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,24008.34,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,28069.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,42104.85,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,28069.9,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,39297.86,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,24008.34,42104.85,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14631.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12065.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12065.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,12065.66,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14631.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,21946.76,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,14631.17,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,20483.64,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,12065.66,21946.76,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9697.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7680.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7680.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,7680.93,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,9697.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,14545.74,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,9697.16,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,13576.02,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,7680.93,14545.74,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1054.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1054.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1581.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,1054.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,1475.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1054.04,1581.06,
UNGROUPABLE,999,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1054.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1054.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1581.06,160,MS-DRG,,other,160% CMS MS-DRG rates for inpatient stay,1054.04,100,MS-DRG,,other,100% CMS MS-DRG rates for inpatient stay,1475.66,140,MS-DRG,,other,140% CMS MS-DRG rates for inpatient stay,,,,,other,Not reimbursed by MS-DRG for inpatient setting,1054.04,1581.06,